Health Declaration

Please fill out the following health declaration form ahead of your upcoming treatment session with Diagnostic Therapy. This form will gauge your suitability to receive treatment and also acts as a consent form, acknowledging the risks involved with face to face treatment under COVID-19 protocols. Submissions are valid up to 24 hours prior to the activity.
*Required

First Name

Last Name

My body temperature is lower than 100.04°F/ 37.8°C

COVID SCREEN: Do you or your household members have any of the COVID-19 symptoms, namely; a fever, new persistent cough, sore throat, shortness of breath, or a loss of taste or smell? (If the answer is yes, your appointment will need to be postponed and you will be required to self isolate)

Yes

Necessity of Treatment:

Do you to your knowledge have any bloodborne pathogens present in your blood, namely Hepatitis B or C, or HIV?

Yes

Date

Initials

By checking this box, I confirm that I am in a healthy enough state to receive soft tissue treatment. I knowingly and willingly consent to have face-to-face treatment with Jonathan Broom-Edwards and/or staff, and I acknowledge the risks involved with face-to-face treatment that is carried out during the COVID-19 pandemic. I understand that the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I consent to all the data above to be stored and managed by Jonathan Broom-Edwards Diagnostic Therapy.

Health Declaration

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34 King Edward Road, Loughborough LE11 1RZ

Six Hills Golf Club, Six Hills, Melton Mowbray

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Health Declaration

Let's Connect

34 King Edward Road, Loughborough LE11 1RZ

​

Six Hills Golf Club, Six Hills, Melton Mowbray

Privacy Policy