First Name *
Last Name *
Gender *
Date of Birth *
Email *
Telephone Number
Have you been to the clinic for treatment before? *
Yes
No
Step 1 COVID-19 Screening
Have you tested positive in the last 7 days *
Yes
No
Are you waiting for a test or results *
Yes
No
Have you developed a new continuous cough? *
Yes
No
Do you have a high temperature or fever? *
Yes
No
Have you experienced a loss of or change your sense of smell or taste? *
Yes
No
Do you live with anyone who has tested positive or had symptoms in the last 14 days? *
Yes
No
Are you suffering any common cold type symptoms or any infectious illness *
Yes
No
Step 2 Accompanied Treatment
Do you need to be accompanied during treatment? *
Yes
No
Step 3 High Risk
Have you received a letter from the NHS to advise you are high risk? *
Yes
No
If yes, for what reason?
Step 4 Vaccination
How many vaccinations have you had? *
0
1
2
Step 5 Pain
Are you wanting treatment for a painful condition? *
Yes
No
Step 6 Room Selection
Are you exempt from wearing a face mask? *
Yes
No
If yes, are you ok to wear a face shield?
Yes
No
Can you cope with stairs? *
Yes
No
If no, can you cope with two steps?
Yes
No
Step 7 Moderate Risk
Do you have any underlying medical problems? *
Yes
No
If the answer is
YES
, please specify
asthma, COPD, emphysema or bronchitis)
Yes
No
Heart disease
Yes
No
Diabetes
Yes
No
Chronic kidney disease
Yes
No
Liver disease
Yes
No
High risk of getting infections
Yes
No
Step 8 About You
Are you pregnant?
Yes
No
Have your GP told you that you are morbidly obese? *
Yes
No
Submit