Hormone Health Consultations
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.
Date Format: 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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