COVID-19 Declaration Form

Please complete this form when you book an appointment with Pauline.

COVID-19 Declaration

Please complete this form for every appointment with Pauline

  • Name*

  • Date

Date Format: MM  DD  YYYY

  • Address

  • Phone*

 

  • Email

Enter Email Confirm Email

  • Have you or anyone in your household ever been diagnosed with Covid-19?*

    • Yes

    • No

  • Have you or anyone in your household shown any of the following symptoms in the last 7 days? New dry cough, rash, diarrhoea, shortness of breath*

    • Yes

    • No

If the answer to this question is yes, then the treatment can not continue until after 2 weeks of isolation with no symptoms in the household.

  • Have you or anyone in your family been advised by the government as being clinically vulnerable and to shield?*

    • Yes - me

    • Yes - family member

    • No

  • Have you recently travelled abroad?*

    • Yes - within the last 7 days

    • Yes - over a week ago

    • No

  • Have you noticed any new rashes on your body or feet?*

    • Yes

    • No

  • Have you experienced any pain or cramping in your legs/calves?*

    • Yes

    • No

  • Do you promise to contact your therapist immediately if you or anyone in your household develops symptoms associated with covid-19 within 7 days of your treatment?*

    • Yes

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

    • Yes

Pauline will contact you the day before to see if anything has changed, and you will also be asked these questions when you arrive for your treatment.