Initial Consultation and Treatment Plan
In Clinic COVID-19 Safety and Guidelines
COVID Consent Form
Have you had a fever in the last 10 days? (Feeling hot to touch on your chest and back)
Do you now, or have you recently had, a persistent dry cough? (Coughing a lot for more than an hour, 3 or more coughing episodes in 24 hours or worsening of a pre-existing cough)
Have you lost sensations of taste and smell?
Have you been in contact with anyone in the last 10 days who has been diagnosed with Covid-19 or has coronavirus-type symptoms?
Have you been told to stay 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 below?
I am the:
I am the patient’s:
If you are signing on behalf of the patient, or the patient is a minor, please state your relationship with the patient below.
I understand that, because my treatment may involved 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.
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.
Specialising in hormone health for women. Expert in alternative support to the menopause.
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. My reception team are ready to take your call from 8am to 7pm (Mon to Fri) and 8.30am to 5.30pm (Sat). If you prefer, please do send me an email or you can book directly online
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