New Consultation Form

Current health issues;

Any recent surgeries or injuries;

Other medical or therapeutic treatments;

Are you experiencing a temperature, persistent cough or loss of taste or smell?

Have you experienced any of the above symptoms in the last 14 days?

Have you or anyone from your household been tested or treated for Covid-19 and if so, how long ago?

Are you following social distancing guidelines?

Are you happy with the new measures introduced and do you have any specific requests?

Signature and Date

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