Name *

First Name

Last Name

Date of Birth *

Please note that this is an American piece of software and because of this the date is entered month first

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please indicate any of the following that apply *

Age over 70

Pregnant

Diabetic

Heart disease

High blood pressure

Overweight

Very overweight (obese)

A condition affecting the brain or nerves

Previous organ transplant

Undergoing chemotherapy

Undergoing treatment for cancer

Immuno-suppressant medication taken in the last 6 months

Use of steroid medication in last 6 months

Lung condition

A condition that places you at increased risk of getting infections

Any other condition that you feel may make you vulnerable to COVID-19

None of the above

Do you come in to contact with anyone who meets the above criteria *

Yes

No

Are you currently taking any medication? *

Yes

No

COVID risk in clinic *

Whilst we have measures in place within the clinic to minimise the risk of contracting COVID, we cannot remove the risk completely. For information on how we manage COVID risk within the clinic please see our policies and procedures (the links to these are displayed at the bottom of each page)

Yes, I understand there is a risk of exposure to COVID and am still happy to attend my appointment

No, I am not happy with the risk and would like to discuss other options (we will call you)

COVID risk within Colchester Fitness Centre *

Colchester Physiotherapy is accessed via the gym area of Colchester Fitness Centre. This means that in order to get to the clinic you will have to pass through the gym area. People will be exercising without masks in this area. Whilst this is a large open space, it does present an additional risk of contracting COVID from people using the gym.

Yes, I understand there is a risk of exposure to COVID and am still happy to attend my appointment

No, I am not happy with the risk and would like to discuss other options (we will call you)

Are you happy for Howie to be in clinic when you are? *

Yes I am happy for a dog to be present during my treatment session

No I do not want a dog to be present during my treatment session (we will rearrange your appointment for a day when Howie is not in clinic)

Do you have an allergy to dogs/dog hair? *

I do not have an allergy to dogs/dog hair

I have a dog/dog hair allergy (we rearrange your appointment for a day when Howie is not in clinic and will remove his bed and toys from the clinic room on the day of your appointment)