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Health Declaration Form – COVID-19

Health Declaration Form – COVID-19

 

*** Required to be completed by every patient prior to commencement of outpatient Physiotherapy treatment at SHAMIM KHAN PHYSIOTHERAPIST

Patient Health Declaration Form
SECTION A: Please read the following statements and then answer either YES or NO below. If NO provide details in the block below the section:
Select Yes or No
Select Yes or No
Select Yes or No
Select Yes or No
SECTION B. Read the following statements and select YES OR NO from the drop-down box. If you answered NO provide reasons in the text area below this section..
SELECT YES OR NO
SELECT YES OR NO
SELECT YES OR NO
SELECT YES OR NO
Select Agree or Disagree to the above condition
Select Agree or Disagree to the above condition
Select Agree or Disagree to the above condition
Select Agree or Disagree to the above condition
Select Agree or Disagree to the above condition
Printing Your Name
Your Contact Number
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