Covid Screening Form

Please fill out the following form within 24 hours of treatment.

Name

Phone Number

Date of Birth

Have you taken a negative Lateral Flow Test within the last 24 hours? Or have you had a positive lateral flow or PCR test within the last 2 weeks?

Yes

Have you travelled abroad recently or been in contact with anyone who has tested positive for covid in the last 2 weeks?

Yes

Do you have any of the following symptoms? Fever, new or persistent cough, shortness of breath, headache, fatigue, upset tummy, other.

Yes

If you answered yes to any question, please elaborate. Use this box to share other relevent information such as exemption from wearing a mask or if you are in a high risk/ vulnerable group for covid.

Initials

I declare that the info I’ve provided is accurate & complete

Thankyou for submitting!

Treatments are given at Lizzie's home in Somersham, nr Huntingdon. Please get in touch to discuss your needs.