Health Check Questionnaire

Name*

First Last

Date*

Email

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Have you tested positive for COVID-19 or been in contact with someone who has within the past 14 days?*

Are you awaiting those results?*

Have you experienced the recent onset of any of the following symptoms of coronavirus (COVID-19):*

a dry continuous cough
high temperature
loss or change of taste and sense of smell
shortness of breath
a positive COVID-19 test
No, I am not experiencing any symptoms of COVID-19

Have you been in contact with anyone within the last 14 days who is now showing any of the above symptoms?*

Whilst every effort will be taken to make the treatment environment as safe as possible, please be aware of the risks involved if you live with anyone who is classed as vulnerable.*

I am aware of the risks and wish to proceed with my appointment

For the purpose of 'Test and Trace' I give permission for my time of entry and departure to be recorded and I am happy for Claire Bowring to contact me if required.*

Agree

Please be aware that I can only allow one client at a time (no guests/children). Please ensure you have read and agree to follow my arrival procedures as set out in my service protocol and procedures statement (they maybe subject to change, please check before each appointment)*

I have read and agree to follow the protocol and procedures

I confirm that to the best of my knowledge, the answers I have given are correct and I have not withheld any information that may be relevant to my treatment. I certify that the preceding details are true and correct . I am aware that it is my responsibility to inform Claire Bowring of my current and ongoing medical or health conditions and to update this history where necessary. I am also aware this information is essential for Claire Bowring to execute appropriate treatment procedures. I understand that failure to disclose information requested above may result in harm to others to which I accept full liability/responsibility. I will follow all the guidance and requests that Claire Bowring asks of me and will be respectful of the environment for her and others using it.*

I agree and confirm

Email

This field is for validation purposes and should be left unchanged.

Health Check Questionnaire

COVID-19 - How I'm working to keep us safe