All information submitted is strictly confidential and only used in protecting us all from the spread of the COVID-19 virus "*" indicates required fields Date* DD slash MM slash YYYY Appointment Date* DD slash MM slash YYYY Name First Last Email Are you unwell with any cold or flu like symptoms including: fevers, cough, vomiting, diarrhoea, night sweats or chills, or acute respiratory infection including cough shortness of breath or sore throat?* No Yes Have you been formally identified as a close contact of a confirmed case?* No Yes Is any person you are living with in self isolation or mandatory quarantine?* No Yes COVID-19 Vaccination status* 3 Vaccinations 2 Vaccinations 1 Vaccination 0 vaccinations Use of hand sanitiser before entering* I agree to then sanitise my hands before enteringMasks -are discretionary and no longer provided by the clinic* ReadPlease advise the practitioner if you would like them to wear a mask during the consultation and they are not already doing so* ReadCOVID-19 Enhanced Hygiene Policy, You may be asked to resanitise your hands at any point during your time in the clinic and we appreciate you complying with these enhanced hygiene measures.* I agree to the enhanced hygiene policy at Integrated Physiotherapy
