Name
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First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone number
*
Email
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Have you or others in your household, experienced: A fever (Above 37.8ºC), a new persistent cough, a new loss of taste or smell, gastrointestinal upset (diarrhoea and/or vomiting), in the past 14 days?
Are you or anyone in your household currently self isolating?
Have you or anyone in your household, knowingly been in close, unprotected contact with a confirmed or probable case of coronavirus infection?
Have you or anyone in your household, travelled to, or returned from, a country outside of the United Kingdom in the last 14 days?
Have you or anyone in your household, been identified as high risk from coronavirus (clinically extremely vulnerable)?
Track and Trace:
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My details can be released to NHS track and trace or other public health authorities, by SportFix Yorkshire, in relation to Covid-19 and I would like to continue with a face to face appointment:
Potential Risks:
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I have been made aware of and accept the potential risks of attending a face to face visit with SportFix Yorkshire, knowing that every effort has been made to reduce these risk as far as reasonably possible:
Thank you for helping to keep our therapists and other clients safe by completing our screening tool.
If you have sent it back before the day of your appointment, please remember to send us a written message by text/email/social media to confirm it is still current on the day. If anything changes please let us know with as much notice as possible.
All being well, we look forward to seeing you.