COVID-19 Declaration Form

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

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COVID-19 Declaration

Please complete this form for every appointment with Pauline

• Name*

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• 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.

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