patient form

Please fill up the form below and copy it to my facebook inbox if you would like to get treatment.

       Full Name                                                  Date of birth

       Address

        Covid-19 screening information

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1) Have you had a fever in the last 7 days? Y_N _(feeling hot to touch on your chest and back)

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2) Do you now, or have you recently had, a persistent dry cough? Y_ N_

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3) Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has coronavirus-type symptoms? Y_ N_ 

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4 )Have you been told to stay home, self-isolate or self-quarantine? Y_ N _

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5 )Do you have any other symptoms that may mean you have a Covid-19 infection? (loss of taste and smell, unusual fatigue or shortness of breath) Y_ N _  

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Consent for treatment I understand that, because my treatment may involve touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including Covid-19. I give my consent to receive treatment from this practitioner.

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Full symptoms :

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Name

Signed

Date