Health Information: Covid-19 Consent Form
Have you had a fever in the last 7 days?
Do you now,or have you recently had, a persistent dry cough?
Have you lost sensations of taste or smell?
Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or who has coronavirus-type symptoms?
Have you been told to stay at home, self-isolate or self-quarantine?
Do you or anyone that you live with fall into the 'clinically vulnerable' or 'clinically extremely vulnerable' categories as defined

Consent for treatment 

I understand that, because my treatment may involve touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including Covid-19. 

I give my consent to receive treatment from this practitioner. 

In the event that my practitioner has to undergo a test for Covid-19 within 48 hours of my treatment, I consent to my details being passed on to NHS Test and Trace.

Your Signature

Contact

Email:

jo@jophillips.com

Salisbury  01722 340736

Fordingbridge  01425 462562   

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© 2019 by Jo Phillips