Sports and Spinal Physio LTD
24 Tallon Road
Hutton
Brentwood
CM13 1TE

Covid-19 Patient Risk Assessment

Covid-19 Patient Risk Assessment

Your Name (required)

Your Email (required)

Telephone Number

Are you following Government guidelines for Covid-19? https://www.gov.uk/coronavirus
YesNo

Have you been in contact with anyone with Covid-19 symptoms in the last 14 days?
YesNo

Have you had any Covid-19 symptoms in the last 7 days?
YesNo

Have you noticed any difference in your sense of smell and/or taste?
YesNo

Are you in a high risk group for Covid 19?
YesNo

Consenting to treatment

I consent to treatment from Sports & Spinal Physio and understand the risks of Coronavirus and appreciate that all precautions are in place to minimise this risk.
YesNo

Digital Signature

Please use the mouse if on a computer to add your signature or your finger if using a tablet or mobile.

Please help us to fight spam by answering the question below:

Pin It on Pinterest