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YING ZHANG
Acupuncture & Chinese Medicine
H O M E
P H I L O S O P H Y
C O N T A C T
Registration Form
T E S T I M O N I A L S
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Covid-19 Free Declaration
Full Name
Email Address
Contact Phone for Track & Trace
My body temperature is lower than 98.6°F/ 37.5°C. high temperature – this means you feel hot to touch on your chest or back (you do not need to measure your temperature)
Have you had a Persistent Temperature, Dry Cough, Loss of Taste/Smell or been in contact with anyone with Covid symptoms or diagnosis in the last 14days?
*
No
Yes
Have you travelled within the last 2 weeks from ”high risk” countries which are not in the government travel corridor list?
*
No
Yes
Have you been told to self Isolate, Quarantine or are you Shielding at the moment?
*
No
Yes
I confirm that I am happy to comply with NHS track and trace and satisfied with the Covid-19 Safety Protocols in place at this premises.
Date
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