Have you experienced any of the following within the last 14 days? *

Please select all that apply.

Fever

Unexplained aches and pains

Coughing

Sore throat

Shortness of breath

Chills (with or without body aches)

Recent loss, or change in, sense of taste and/or smell

Unexplained sores on soles of the feet

Unusual fatigue

Non-allergy related runny nose

I have not experienced any of the symptoms listed above within the last 14 days.

Confirmation *

Please confirm that the above information is accurate. If you selected any of the symptoms listed above, you will not recieve the scheduled treatments and arrangements will be made to reschedule your appointment. Please tick the box below to confirm that the information supplied is accurate.

I confirm the above information is accurate and complete.