COVID-19 Declaration

You must return a COVID Declaration within 24 hours of every face to face appointment. If your appointment is more than 24 hours from now, please come back later.

Please complete all parts of the declaration then click the submit button.

(A message will be displayed to confirm whether your form has been submitted successfully.)

Appointment Date




















Chirozone are making every effort to limit the possible transmission of COVID-19, but there cannot be zero risk when offering face-to-face care.





Please ensure that the email address you have entered is correct. We will send you a copy of the declaration for your records.

I agree to the storage and handling of my data by Chirozone.

If you would prefer to print and complete on paper, please download the .pdf version here, then return a scan, or good quality photo to forms@chirozone.co.uk