Covid-19 Patient Risk Assessment

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

Signature: 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 sign your name below.(To draw your signature: Place the mouse cursor in the area below, click and hold the left mouse button then move the mouse as if you were drawing/ or use your finger if on phone or tablet)

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Covid-19 Patient Risk Assessment

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