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

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