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Email Address

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Do you now, or have you had in the last 14 days, any know symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, changes in taste or smell, or any flu like symptoms? Do you now, or have you had in the last 14 days, any know symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, changes in taste or smell, or any flu like symptoms? Yes No

Have you been diagnosed with or suspected of having COVID-19 infection in the last 14 days? Have you been diagnosed with or suspected of having COVID-19 infection in the last 14 days? Yes No

Have you been confirmed or suspected of being a close contact of a person, who has been a confirmed or suspected case of COVID-19 in the last 10 days? Have you been confirmed or suspected of being a close contact of a person, who has been a confirmed or suspected case of COVID-19 in the last 10 days? Yes No

Have you been advised by a doctor to self-isolate at this time? Have you been advised by a doctor to self-isolate at this time? Yes No

Please note: If you have answered yes to any of the above questions you should not attend a face-to-face manual therapy treatment. By submitting this form you consent to the COVID-19 policy above and have answered no to all the above questions. AME Healthcare Clinic is a medical facility and therefore we kindly ask that face coverings are worn by all attendees. This is to protect both our patients and healthcare providers.