COVID Form — Acupuncture, Reiki & Life-Coaching

Contact Number

Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?

Have you been in close contact with a confirmed or suspected case of COVID-19 in the last 14 days?

(i.e. less than 2m for more than 15mins accumulative in 1 day)

Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days?

Have you been advised by a Doctor or the HSE to self-isolate at this time?

Have you been advised by a Doctor or the HSE to cocoon at this time?

I understand that this information is required for the purposes of public health and will be kept on file for a 2 month period from the date of signing. I confirm that the above information is true and accurate from the date of signing. I understand that my personal information including my name and contact details may be shared with the Health Service Executive(HSE) for the sole purpose of contact tracing in line with public health guidelines only if requested.

Please type your name below

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Clinic located in Lotus Loft, Beach Court, Unit 3, Kilcoole, Co. Wicklow A63 C3WO