It is essential that everyone attending the clinic for treatment completes this questionnaire to ensure that we reduce the transmission of COVID-19. If you are experiencing any symptoms of the virus please do not come to the clinic. 

Question Title

* 1. Have you had a temperature above 37.8oC in the past 2 weeks?

Question Title

* 2. Have you had a persistent cough in the past 2 weeks?

Question Title

* 3. Have you developed shortness of breath in the past 2 weeks?

Question Title

* 4. Have you visited a country in the past 2 weeks that requires you to self isolate?

Question Title

* 5. Do you work, or have you attended a facility that treats COVID-19 patients in the past 2 weeks?

Question Title

* 6. On arrival at the clinic you will have your temperature taken via non contact infra red thermometer, please confirm that you consent to this.

Question Title

* 7. How concerned/anxious are you about the current COVID-19 situation?

Very concerned Not at all concerned
Clear
i We adjusted the number you entered based on the slider’s scale.
The team at Aligned For Life Chiropractic endeavour to uphold rigorous hygiene procedures and have protocols in place to attempt to reduce the spread of COVID-19. However, whilst we have attempted to reduce the risk of transmission of the virus we can not guarantee that there is no risk whilst attending your appointment.

Question Title

* 8. I understand that there is the risk of transmission of COVID-19 (coronavirus) whilst attending for my appointment at Aligned For Life Chiropractic and I am happy to receive treatment.

If you develop any COVID-19 symptoms after completion of this questionnaire, are concerned about receiving treatment or feel that your symptoms have significantly improved you can cancel or reschedule your appointment without incurring any late cancellation fees.
0 of 8 answered
 

T