• Covid-19 Pre-Consultation Form

    To help prevent the spread of Covid-19 in the clinic and the local community, each client must complete and sign this form before attending for treatment. On review of the form, I may contact you to discuss. NB - EVERY QUESTION MUST BE ANSWERED. I kindly ask that you compete and return the form at least 12 hours in advance of your treatment. Together we can help keep everyone safe! Thank you.
  • Do you have/have you had any of these symptoms in the past 14 days? Cough, shortness of breath, sore throat, high fever, muscle pain, body ache, nausea, loss of taste/smell*
  • Have you ever been diagnosed with confirmed COVID-19 infection?*
  • Have you been in close contact with a person who is a confirmed or suspected case COVID-19 in the past 14 days? (ie: less than 2 meters for more than 15 mins in a day)*
  • Do you consider yourself to be in the category of people at a higher risk from COVID-19? (If you are unsure if you are in an at-risk category, please visit https://www2hse.ie/conditions/coronavirus/people-at-higher-risk.html*
  • Have you been advised by a doctor to self isolate at this time?*
  • Have you been advised by a doctor to cocoon at this time?*
  • By checking the boxes, you confirm that you agree with the following statements:*
  • If your situation changes after you complete this form, you agree to inform your therapist ASAP in advance of your appointment

  • I consent to my contact details being held on record and shared, if asked, with HSE personnel for the explicit purpose of contact tracing in respect of COVID-19, as required by current government guidelines.

  • I agree not to visit the treatment room for any of the services provided if I have the symptoms of COVID-19. I acknowledge that the information I have given in this consent form is accurate and complete. By signing below, I confirm that I understand and agree to all terms and statements in this form.

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