Full Name *

Phone number *

Email *

Date of Birth DD/MM/YYYY *

Address *

Do you have cough, fever, breathing difficulty or sore throat? *

Did you have any kind of contact with patient who recently tested covid 19 positive? *

I promise to wear mask through out the physiotherapy session. *

I am competent to give and hereby give my informed consent for clinical and physical examination of the above named patient, for conduct of investigations deemed necessary and for treatment of the said patient by medical staff at Zelus Healthcare. I hereby declare that all the entries made above are true, correct and fair to the best of my knowledge. *