COVID-19 Patient Form Full Name (Required) I hereby declare that I or anyone in my household has not experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing). If I or anyone in my household experienced any cold or flu-like symptoms after submitting this form, I will not visit the clinic for a minimal period of 14 days after the cold or flu-like symptoms have completely gone away. I agreeI do not agree I acknowledge that I have not been in close contact with any individuals who have a confirmed or presumptive positive diagnosis of COVID-19 in the past 14 days. I agreeI do not agree I hereby declare that if there is any change to the above status at the time of my visit to TSL Physio that I will call the clinic to advise them and cancel my appointment. I agreeI do not agree This form must be completed PRIOR to your first visit back with TSL Physio. If you have already completed this form post clinic re-opening, you are not required to fill out again at this time. You only need to complete this form once for any services with TSL Physio scheduled from June 8th 2020 onward.