Muscle Tussle COVID-19 Pre-Treatment Questions
Please complete and submit this form before your treatment (ideally no more than 24 hours before)

Please get in contact if you have any questions: or 07886991892

Thank you
Email address *
Full name *
Contact number *
Date of the treatment *
Do you currently have COVID-19 or any symptoms of COVID-19? *
Please defer your treatment if you: Are waiting for a COVID-19 test result; have recently tested positive for COVID-19; or have a high temperature, new continuous cough, or loss or change to your sense of smell or taste. If you currently have symptoms of COVID-19 but have not yet used NHS 111 Online Coronavirus Service, please do so. If you have any other new or unusual symptoms, please discuss these with us before your appointment.
Have you had COVID-19? *
If you have had COVID-19 please seek consent from your GP or Consultant before treatment.
Does anyone in your household have COVID-19 or symptoms of COVID-19? *
If yes, please defer your treatment until it is safe to do so.
Have you been in close contact with anyone else in the past 14 days who has symptoms of COVID-19, or been contacted by NHS Test and Trace Service and told to self isolate? *
If yes, please defer your treatment until it is safe to do so.
Are you classed as a 'extremely vulnerable' person (high risk)? *
If you are classed as 'clinically extremely vulnerable' and require shielding, you will have received a letter from the NHS explaining this. Defer treatments until the Government indicates that it is safe for you to leave home or have visiting providing non-essential care.
Are you classed as a 'vulnerable' person (moderate risk)? *
Unlike people at high risk, those who are classed as clinically vulnerable will not have received a letter from the NHS. If you are unsure if you are clinically vulnerable please refer to If you meet the definition of someone who is clinically vulnerable, please discuss this further with your therapist and you may need to seek consent from your GP, Midwife or Consultant before having a treatment.
In light of all the changes and restrictions due to COVID-19, do you have any concerns or hesitations that you would like to discuss before your treatment?
I, the named person above confirm that: *
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