Name *

First Name

Last Name

Date *

MM

DD

YYYY

In the last 14 days, have you been in close contact (less than 2 metres) with someone who has confirmed COVID-19? *

Yes

No

Are you awaiting on Covid-19 test results? *

Yes

No

Have you experienced any of the following symptoms in the last 14 days? *

Fever

Dry Cough

Sore Throat

Shortness of Breath

Loss of taste and/or smell

None of the above

Have you travelled overseas in the last 14 days? *

Yes

No

I agree to immediately notify you if I contract the virus within 14 days following my visit *

Yes

I understand that I may be unable to proceed with my appointment if it is deemed unsafe for myself or Relax Therapy *

Yes

Please confirm your name in agreement to the above *

First Name

Last Name