+91 93256 09388
Our physiotherapists are following all safety guidelines issued by WHO to ensure utmost safety of the patients and family members. We are happy to extend our continued physiotherapy support in these tough times. Call
+91 9325609388
+91 93256 09388
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SELF-DECLARATION FORM
Due to the ongoing and rapid changing situation with the novel-coronavirus (COVID-19), we have made it mandatory for our patients to fill this self declaration form below. Depending on this form, HealYos will assign the physiotherapist/doctor on call for a visit at your location. Every patient must complete this form prior to their appointment and submit it.
Patient Name* :
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Mobile Number:
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Email id:
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1. Do you have following any of following flu-like symptoms ?
Fever (38°C/ 100° F)*:
No
Yes
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Cough:
No
Yes
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Breathlessness:
No
Yes
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Sore Throat:
No
Yes
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Loss of Smell and taste:
No
Yes
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Others (Please specify) :
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2. Have you ever been COVID positive ? :
(*)
No
Yes
please upload your recent report
If Yes, Please submit your recent test report
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3. Have any of your immediate family members been COVID positive ? * :
No
Yes
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If Yes, Please submit your recent test report
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4. Have you or an immediate family member come in close contact with a suspected or confirmed case of the coronavirus in the last 14 days ? (“Close contact” means being in the same room for more than 15 minutes.):
No
Yes
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5. Does your society building or area have suspected or confirmed COVID 19 patients?:
No
Yes
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**The health and wellbeing of our community is our first priority therefore HealYos reserves the right to postpone the treatment/service of its patients under certain circumstances**
‘I accept that the above information is true to my knowledge and I have read all the safety guidelines and will strictly follow them. I understand the risk involved in home health care services in current situation and I am willing to schedule a session at home.’
(*)
AGREE
DISAGREE
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Captcha
(*)
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Contact Us
Patient Self-Declaration-Form
Career Opportunities
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Physiotherapy Treatment at Home
Stitch or Suture Removal/Wound Dressing At Home
Fall Proofing Program
Complete Covid Care at Home
Post Covid Care at Home
Surgical and Medical Equipment
Healyos Rehabilitation centre
Healyos Senior Care Program
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