Contact Tracing Form

Name

First Last

Date

Time of Appointment

Email

Temperature

Phone

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Have you any of the following COVID-19 symptoms?: Fever (Over 38 degrees C/100.4 F)

Yes
No

Have you been diagnosed with COVID-19 infection in the last 2-3 weeks?

Yes
No

Have you been in contact with a a positive COVID-19 person in the past 2-3 weeks?

Yes
No

Have you been advised by a doctor to self isolate at this time?

Yes
No

Have you returned from abroad in the last 14 days?

Yes
No

Client Signature

Date

I accept the terms of the Athlone Physiotherapy & Pilates Privacy Policy

If you have answered 'YES' to any of the above questions you will need to re-schedule your appointment for approximately 2-3 weeks. A follow up phone call before the rescheduled appointment will be made to go through the questionnaire again.

PLEASE NOTE THAT THE INFORMATION ON THIS FORM WILL BE TREATED IN THE STRICTEST CONFIDENCE IN LINE WITH OUR GDPR POLICY ON SENSITIVE PERSONAL INFORMATION

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Comments

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