Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Phone

Address

Child's Name (if applicable)

Have you experienced any of the following symptoms within the last 14 days? Please tick if applica le.

Dry cough

Fever

Flu like symptoms

Other symptoms including aches and pains, sore throat, headache or loss of taste or smell

None of the above

Have you travelled internationally within the last 14 days?

Yes

Have you come into contact with any suspected, probable or confirmed COVID-19 cases within the last 14 days?

Yes

Please read each of the following statements carefully and tick to indicate that you agree.

I agree to follow strict hygiene practices while at my appointment including washing or sanitising my hands on arrival, and will comply with staff instructions during my service.

I will not bring anyone unrelated to my service with me to help limit the number of people on the premises.

I agree to maintain a physical distance as much as possible and understand some elements of my visit may be slightly different to accommodate social distancing guidelines.

I understand that in the current, fast moving climate, my appointment may need to be rescheduled with short notice. If this happens, a new time will be found in line with any government guidance.

I agree to let you know if any of the details I have given change, particularly with regards to developing any symptoms of, or exposure to COVID-19.

I declare that the info I’ve provided is accurate & complete

Your Signature

Date

Thanks for submitting!

ABOUT

Focus within Health & Wellbeing
is passionate about working
with people to achieve their
wellbeing potential.

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8 La Valla Court
Junortoun VIC 3551
info@focuswithinhw.com
0438 449 507

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