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Self-referral form

Please do not attend your physiotherapy appointment if you have any of the following:

  • Positive COVID-19 test in the last 7 days?
  • Waiting for a COVID-19 test or the results?
  • New, continuous cough*
    • * A new, continuous cough means coughing for longer than an hour, or three or more coughing episodes in 24 hours. If the patient usually has a cough, it may be worse than usual.
  • High temperature or fever
  • Loss of, or change in, sense of smell or taste
  • You live with someone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days?

Click next to complete the COVID-19 Screening Questionnaire

Covid-19 Screening

I confirm the information provided is truthful to the best of my knowledge.
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