Covid-19 Pre-Screening

I, ……………………………………..confirm that I have not been in contact with, tested for, or had any COVID-19 symptoms such as fever with a temperature above 37.5 C, shortness of breath/breathing difficulties, chills, persistent dry cough or muscle pain, during the last three weeks.
I understand that it is my responsibility to ensure that thehealingtouchway clinic are informed should any symptoms appear either prior to or during the three weeks following my appointment in clinic.
I agree that I have not knowingly been exposed to someone with COVID-19, or recently returned from an area of high infection, travelled by air or ship or been at risk where social distancing was not properly observed.
I agree that I do not fall into the most vulnerable or high risk category due to significant health issues or my age group and that I have not been told by my health officials to self-isolate and to remain at home.
Name:……………………………………………….. Date: / /2020
Signed: ………………………………………………
Witnessed by Patricia Harbot Signature:…………………………………………………..