Covid-19 Client Questionnaire/Declaration

Thank you for filling out our consultation form. Please take a moment to fill out our COVID-19 client questionnaire.

My priority at this time is to keep both clients and myself as safe as possible. In order to achieve this, I have taken measures in line with the current Coronavirus government guidelines and are duty-bound to ask you the following set of questions. I assure you that the information you give remains confidential unless legally bound to release it. Thank you for your support.

Are you currently experiencing any symptoms of COVID-19?

Are you experiencing any of the following symptoms which have suddenly become apparent (tick those that apply)?

Is anyone in your household experiencing any symptoms of COVID-19?

Have you been in contact with anyone else with any COVID-19 symptoms in the last 7 days?

Have you returned from travelling abroad in the last 14 days?

Please note that I am obliged to notify NHS track and trace if circumstances require such. if I report any symptoms among clients or myself, or I am contacted by Track and Trace, I am legally obliged to provide them with your contact details and you may be contacted.

Do you promise to contact me immediately if you or anyone in your household develops symptoms, associated with COVID-19 within 7 days after your treatment

If anything changes between now and your appointment time, do you promise to inform me before your appointment date?

10 + 15 =