Every patient is required to complete this on the day of treatment for each appointment.

Additional information on the steps being taking by Clare Smith Acupuncture for Covid 19 can be found at claresmithacupuncture.com.  This includes information regarding your treatment.

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* 1. Name

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* 2. Date of birth

Date

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* 3. Email

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* 4. Address

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* 5. Covid 19 Screening Information

  Yes No 
Have you had a fever in the last 7 days? (feeling hot to touch on your chest and back)
Do you now, or have you recently had, a persistent dry cough? (coughing a lot form more than an hour, 3 or more coughing episodes in 24 hours or worsting of a pre-existing cough).
Have you lost sensations of taste or smell?
Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid 19 or has coronavirus type symptoms?
Have you been told to stay home, self isolate or self quarantine?
Do you or anyone you live with fall into the 'clinically vulnerable' or 'clinically extremely vulnerable' categories as defined below

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* 6. Consent for treatment: I understand that because my treatment may involve touch and close physical proximity over an extended period of time there may be an elevated risk of disease transmission including Covid-19

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* 7. I give consent to received treatment from Clare Venters Smith

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