Covid-19 Pre-Assessment Screening

Full Name (with surname) *

Contact number *

Email address *

Do you have the following symptoms? *

High temperature
New and persistent cough
Loss or change to your sense of smell or taste
None of the above

Are you in the high risk category? *

Yes
No

Do you have any underlying health conditions including respiratory conditions? *

Yes
No
Not sure

Has anyone in your household had Covid-19 related symptoms in the last 14 days *

Yes
No

Is anyone in your household in the high risk category? *

Yes
No

Have you or anyone in your household been in contact with a suspected or confirmed Covid-19 case in the last 14 days? *

Yes
No

I understand that a virtual appointment is available to me? *

Yes
No

We request that in order to protect our team and other patients, you must wear a face cover/mask whilst at the clinic. Please bring your face cover/mask with you and wear upon entering the building. Are you happy to do so?** *

Yes
No

**Should you forget your face cover/mask we have limited supplies at the clinic and you can purchase one for £1 to be paid to the practitioner directly by CASH only.

I understand I must not bring anyone else in to the building with me?* *

Yes

* Children are allowed a parent or guardian with them if they are under 16. The parent or guardian in question will also be required to fill out a separate pre-screening form

I understand I must arrive on time and the waiting area is out of use? Please wait in your car until the practitioner calls you in to building. Please ensure your face covering/mask is on before entering the building. *

Yes

I understand I must wash my hands on arrival or use hand sanitiser at the clinic when entering the building? *

Yes

I understand payment for my treatment may be taken before or after the consultation depending on when the reception area is most quiet? *

Yes

I will respect the 2 metre distance when in common areas of the clinic? *

Yes

Other comments

I understand that manual treatment at The Harrison Clinic means that a 2 metre distance between myself and the practitioner cannot be maintained. I fully understand the risk associated with this and consent to this. *

Yes, Confirmation & Consent
No

Covid-19 Pre-Assessment Screening

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