Health Declaration Form | Mā Śucaḥ Āyuṣhkendra (MSA)

Health Declaration & Consent Form

Please fill out the following health declaration and consent form before proceeding for an in-person consultation with Dr (Ayu) Sathyavathi S.

Dr (Ayu) Sathyavathi S. declares to the best of her knowledge that she does not have any symptom nor has she come in contact with anyone who tested positive for COVID-19. If the conditions change, she will inform you of the same.

Your full name

Do you have any flu like symptoms (fever, cold, cough, etc.)?

Have you tested positive for COVID - 19 before? If yes, what was the date when you tested negative?

Have you come in contact with anyone who has tested postive for COVID - 19 in the last 14 days?

Are you a NHS front line worker/ Carer/ Shielding a vulnerable adult/ Pregnant/ Over 70 years?

Date

Initials

I confirm that the information given in this form is true and that if the conditions change I will immediately inform Dr (Ayu) Sathyavathi S. Also, I consent to seek consultation in person with her.

Thanks for submitting!

Health Declaration & Consent Form

Please fill out the following health declaration and consent form before proceeding for an in-person consultation with Dr (Ayu) Sathyavathi S.

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Dr (Ayu) Sathyavathi S. declares to the best of her knowledge that she does not have any symptom nor has she come in contact with anyone who tested positive for COVID-19. If the conditions change, she will inform you of the same.

Mā Śucaḥ Āyuṣkendra