Covid-19 Health Declaration & Treatment Consultation
Face masks must be worn at all times throughout your treatment.
Full Name
Email
Myself or anyone in my household have not been advised to shield by the government
I am not experiencing any of these symptoms: fever, cough, sore throat, loss of taste or sense of smell (or any other flu like symptom)
I have not been in close contact with anyone who has tested positive for Covid-19 within the last 14 days
Please select any that may apply:
Pregnant
Severe headaches
Any skin rash or condition
Arthiritis
Diabetes
Varicose Veins
Surgeries (within past 12 months)
High blood pressure
Fibromyalgia/ Chronic fatigue
Any contagious disease/ Illness
Allergies to Acrylics, Plastics, Other
Inflammation/ Swelling
Injuries (within past 12 months)
Other medical condition
I declare that the info I’ve provided is accurate & complete
Initials
Date
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