New patient form

    I understand that as part of my treatment I will receive certain communications.

    I would also like to receive marketing communications via the following method:

    Please identify up to 3 activities that you are not able to do or are having difficulty with as a result of your problems:

    COVID-19 Questions

    I have not had any of the following symptoms in the last 14 days - fever, shortness of breath, loss of sense of taste or smell, dry cough, runny nose or sore throat -

    I have received the COVID vaccination ?

    I did not travel abroad in the last 10 days:

    To the best of my knowledge, I have not been in close contact with anyone with confirmed COVID-19 in the last 14 days.

    I understand that coronavirus may not cause symptoms in some people and is currently causing a pandemic which means healthcare services are required to operate differently:

    If required and appropriate, I can confirm that I have had a telephone / video triage appointment before I attend in person:

    I am aware of the requirements for social distancing, hand sanitising, wearing a face mask covering when at the clinic:

    I am aware of the requirements for wearing a face mask during the consultation:

    I understand that the clinician will wipe down all surfaces in the clinic room before and after my visit and the osteopath/ therapist will be wearing PPE as per regulatory body and government guidelines.