Covid 19 Health Questionnaire

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Due to the current Coranavirus pandemic you are required to complete a short health questionnaire & temperature check prior to your treatment at Therapy Room for both your safety & that of your therapist.

The temperature check will be carried out by an Infra Red thermometer on arrival but please complete and submit the Covid 19 Health Questionnaire below before your visit. All data is private, securely stored and not used for any other purpose other than checking that you do not have any symptoms of Covid 19 prior to a treatment at Therapy Room & if an outbreak should occur locally, for notification purposes.

Please read our Covid 19 Policy by clicking here

Covid 19 Health Questionnaire

I have not been diagnosed with or cared for someone diagnosed with COVID-19 in the past two weeks I have not been diagnosed with or cared for someone diagnosed with COVID-19 in the past two weeks

I have not shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks. I have not shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks.

I do not have a cough, fever, chills, shortness of breath, loss of taste or smell or any other recognised symptoms of COVID-19. I do not have a cough, fever, chills, shortness of breath, loss of taste or smell or any other recognised symptoms of COVID-19.

If I begin to show symptoms of COVID-19 within the next two weeks, I will contact Therapy Room. If I begin to show symptoms of COVID-19 within the next two weeks, I will contact Therapy Room.

I will follow all posted Therapy Room COVID-19 policies, to keep myself, my Therapist and those around me safe. I will follow all posted Therapy Room COVID-19 policies, to keep myself, my Therapist and those around me safe.

Have you received 1st Covid 19 Vaccine

Have you received 2nd Covid 19 Vaccine

Name

Email Address

Phone no:

Date

Signature (Please type name again to sign)

Contact Us

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028 7744 5050

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24a Windyhill Rd, Limavady

BT49 0JW

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info@therapyroomni.co.uk

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Opening Hours

Wed, Thurs, Fri 10am - 6pm

Closed Mon, Tues, Sat, Sun

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This contact form collects your name, email address and message. Is is used solely for the purpose of email contact between you and Therapy Room NI and no other purpose. Visit our privacy policy where you’ll get more info on where, how and why we store your data.