Name *

Address & Postcode *

Date Of Birth *

Phone number *

Email *

Have you had a fever in the last 10 days? (feeling hot to touch on your chest and back) *

Do you now, or have you recently had, a persistent dry cough?(coughing a lot for more than an hour, 3 or more coughing episodes in 24 hours or worsening of a pre-existing cough) *

Have you lost sensations of taste and smell? *

Have you been in contact with anyone in the last 14 days who has beendiagnosed with Covid-19 or has coronavirus-type symptoms? *

Have you been told to stay home, self-isolate or self-quarantine? *

Do you or anyone that you live with fall into the ‘clinically vulnerable’ or‘clinically extremely vulnerable’ categories as defined below? *

Consent for treatment: I understand that, because my treatment may involve touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including Covid-19. I give my consent to receive treatment from this practitioner. *

I am the *