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:…………………………………………………..