Personal Details

Name: ​ ​ ​
Address:
Have you had any of the following symptoms in the last 14 days: fever, dry, persistent cough, or loss of
sense of taste & smell.
Yes c No c
Have you been in close contact with anyone with confirmed COVID-19 in the last 14 days.
Yes c No c
I have received via email, and read the COVID-19 Patient Safeguarding Information document
explaining the precautions taken by Physio 4 Wycombe.
Yes c No c
I confirm that I will inform my therapist if I or anyone else I live with develops symptoms and/or is
diagnosed with Coronavirus whist I am undergoing treatment.
Yes c No c
I confirm I am aware that the clinic requires me to wear a face-covering whilst inside the clinic.
Yes c No c
I understand that my physiotherapist is required to wear full PPE as set by Public Health authorities during
my appointment and this is not optional for them.
Yes c No c

Signed Patient ………………………………………………………………………..

Signature of person with parental responsibility / person legally entitled to sign on behalf of a person
who lacks capacity.

Signed Therapist……………………………………………………………………….Date:
………………