Coronavirus Self-assessment Form - Zest Podiatry & Physio

Thank you for taking the time to complete this form. It must be completed within 48 hours before every appointment.

Name *

First

Last

Email *

DOB

Contact Number

Address

Have you been to one of the COVID-19 affected countries in the last 14 days? *

Please specify any cities/countries you have travelled to within the last 14 days (none if appropriate)? *

Have you been in close contact with a suspected OR confirmed case of COVID-19? *

Are you currently experiencing COVID-19 symptoms (new continuous cough, shortness of breath, fever (>37.5c) or a loss of smell/taste? *

Please specify details of any symptoms from above (none if appropriate) *

Emergency Contact Name *

First

Last

Emergency Contact Number

By electronically signing and submitting this form, I hereby confirm that the information I have given above is true to the best of my knowledge and belief. I will comply with all advice and any rules, regulations and instructions given by Zest Podiatry when accessing treatment and advice be it offsite, at home or attending the Oxford clinic. I understand the Zest Podiatry are unable to give me any guarantee that either themselves or their premises are COVID-19 free. I accept that there is a risk of contracting COVID-19 by accessing any healthcare facility in the UK at this time. I will not hold anyone connected with Zest Podiatry liable in any way should I contract COVID-19 when accessing their services.

I agree to all above and have answered honestly.

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