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Covid 19 Form for Therapy clients
Please complete the following form prior to booking a treatment at Magenta Therapy.
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Full Name *
Date of Birth *
MM
/
DD
/
YYYY
Contact number *
Have you experienced any of the following symptoms in the last 14 days?(tick those that apply) *
Required
If yes, are these symptoms new or part of a pre-existing health condition? Please explain.
Does anyone in your household currently have Covid-19 symptoms or a positive test result? *
Have you been in contact with someone who has been diagnosed with Covid-19 in the last 14 days or been contacted by Track and Trace and asked to self-isolate? *
Are you classed as vulnerable or very vulnerable/shielding during Covid-19? *
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