Therapist COVID-19 Screening Form

The following form must be submitted by any therapist attending the clinic. Nadia will acknowledge that your form has been accepted, allowing you to make bookings on receipt. Thank you for understanding that we must have a safe place to work and visit.

Full Name *

Email Address *

Please tick to confirm the following statements are true to you:I am not suspected to have had or suffered from COVID-19 virus in the last 14 days. And if I am unwell I will not attend the clinic.I agree to inform Nadia if I have any health concerns that she needs to be aware of.I am aware that I must advise clients to keep accessories to a minimum i.e. no; handbags, shopping bags or luggage that are not required for your visit to the clinic (reducing the risk of cross contamination).I must attend my appointment on time and vacate the room promptly 3-5 minutes prior to the end of the slot so that there are no cross overs in corridors.I understand that I must not attend the clinic if any of my health circumstances/risks change prior to me attending my appointment and I must inform the clinic immediately.I am aware that I should ensure the above statements are true of my clients prior to attending the clinic (unless agreed via email by Nadia)..Hand sanitiser and cleaning products are located on shelves in each of the therapy rooms should you wish to use them.I must send an SMS to 07960 121 865 for cancellations.

If there is a/any box not ticked above, please give details why:0 / 50

Relevant health conditions that you feel we should be aware of (please list any):i.e. Do you suffer from any of the following? Diabetes, cardiovascular disease, including hypertension, any respiratory disorders chronic lung disease, immunodeficiency, cancer under active treatment?0 / 180

Standard Operating Procedures *Yes, I agree and have read the Standard Operating Procedures (SOP). 

SCORE 12/12

Submit Form - Confirm

Please do not fill in this field.

We ask that no bookings be placed on our online diaries from the 7th of July 2020 until your submission of the above form has been accepted.