Covid-19 Patient Risk Assessment

Please complete the screening form below. Please refer to Government guidelines and advice here

We look forward to seeing you in clinic very soon.

In the meantime, please familiarise yourself with our in clinic protocols as your understanding and adherence to the protocols is essential.

Click here for our up to date clinic protocols.

Patient Full Name (required)
Patient email (required)
Contact number
Are you following Covid-19 guidelines set out by the Government? https://www.coronavirus.gov/
- Yes
- No
Have you been in contact with anyone who has had Covid-19 related symptoms in the last 14 days?
- Yes
- No
If you answer YES we will require a copy of YOUR test result before we can provide treatment. SEE BELOW.
Have you had any Covid-19 related symptoms in the last 7 to 10 days?
- Yes
- No
If you answer YES we will require a copy of the test result before we can provide treatment. SEE BELOW.
IF YOU HAVE HAD A TEST PLEASE UPLOAD A SCREEN SHOT OF YOUR TEST RESULT.
Drop files here or
Have you noticed a difference in your sense of taste or smell in the last 7 to 10 days?
- Yes
- No
Based on Government gudelines do you fall into the Covid-19 high risk group?
- Yes
- No
Do you consent to treatment with The Flying Physios team?
- Yes
- No
I consent to treatment with The Flying Physios and fully understand the risks associated with Coronavirus and understand and appreciate that all precautions have been put in place to minimise the risk of cross infection. Please print your name below.
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