COVID-19 Client Questionnaire / Declaration
Our priority at this time is to keep both clients and therapists as safe as possible.

In order to achieve this we have taken measures in line with the Coronavirus act of 25th March 2020 and are duty bound to ask you to complete the following form no more than 24 hours prior to your treatment and to contact your therapist if you have any questions. Please defer your treatment if you are waiting for a COVID-19 test result or have recently tested positive for COVID-19.

We assure you that the information you give remains confidential (in accordance with GDPR guidelines), unless we are legally bound to release it.  We thank you for your support and consideration.
Sign in to Google to save your progress. Learn more
Email *
Your full name: *
Date of birth:
MM
/
DD
/
YYYY
Address:
Contact telephone (preferably mobile):
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy