COVID-19 Declaration and Current Symptoms

Please complete this within 24 hours of your appointment.

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

    COVID-19 Declaration

    Current Symptoms
    This information is required for regular chiropractic appointments, but is optional for Massage, Acupressure Massage and Reflexology patients.

    Please give a few words to let us know how you are getting on since your last session:
    (For new problems/re-exams, please give more details including things like: symptoms, onset, duration, cause, etc.)

    List any medications you are taking for this problem.

    Any changes to your medical history since your last appointment? Brief details and
    dates please.

    Thank you for providing the above information. It helps us keep track of your progress and will be added to your notes.

    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