COVID-19 Sign In Check List

In line with our COVID-19 Health Policy, and to ensure the safety of our staff and all visitors to our clinics, we require all clients to complete the questionnaire on this page to provide details regarding their recent movements and any potential exposure to COVID-19.

Please complete this form prior to attending our clinic for your appointment to ensure there are no delays or issues with providing your treatment.

    First Name

    Surname

    Date Of Appointment

    Which Elite Myotherapy Clinic are you atending?

    Have you been to any of the Exposure sites listed as Teir 1, 2 or 3 as listed on coronavirus.vic.gov.au/exposure-sites ?

    Within the last 14-days, have you experienced a new cough that you cannot attribute to another health condition?

    Within the last 14-days, have you experienced new shortness of breath that you cannot attribute to another health condition?

    Within the last 14-days, have you experienced a new sore throat that you cannot attribute to another health condition?

    Within the last 14-days, have you experienced new muscle aches that you cannot attribute to another health condition or a specific activity such as physical exercise?

    Within the last 14-days, have you had a temperature or the sense of having a fever?

    Within the last 14 days, have you had close contact, without the use of appropriate PPE, with someone who is currently sick with suspected or confirmed COVID-19?

    If you answer YES to any of the questions, could you please explain any reasoning, you may need to obtain a Covid-19 test and self-isolate for 14 days.