Covid-19 Appointment Form

Name

Have you got a high temperature?

Yes No

Do you have a persistent new cough?

Yes No

Have you recently lost your sense of taste/or smell?

Yes No

Have you had any of these symptoms in the last 14 days?

Yes No

Have you or anyone directly close to you had COVID-19, been tested for it or received treatment for it? If so, when?

Are you or anyone you have been in close contact with self-isolating at the moment?

Yes No

Are you shielding anyone you have close contact with at the moment?

Yes No

Have you followed social distancing guidelines as set out by the government? (Please be aware it is important to answer this truthfully).

Yes No

Acceptance of new Covid-19 protocols

By checking this box, you confirm that you have read, understood and agree to the new Covid-19 protocols at Radford Holistic Therapies that have been implemented.

You can view the policy online.

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