Appointment request form

Pre-Appointment COVID-19 Screening

To ensure we operate in a safe environment whilst we deliver chiropractic care, please answer the following screening questions related to COVID-19.

In the past 14 days, have you had a respiratory infection with any of the following symptoms?(Required)

Cough
Fever
Shortness of breath
Sore throat
Sneezing
Runny nose
Loss of sense of smell or altered sense of taste

Yes

In the past 14 days have you:(Required)

Received a positive COVID-19 test result, or
Been tested for COVID-19 and is awaiting results, or
Had contact with a COVID-19 case

Yes

If you have cold, flu or COVID-19 symptoms, please stay home and call your doctor or Healthline on 0800 358 5453 for advice about getting tested. We will have to defer your appointment according to Ministry of Health guidelines. Please contact us on 09 526 2100 to schedule an appointment at a later time.

Your Contact Details

Name(Required)

First Last

Email(Required)

Phone(Required)

Preferred date(Required)

Preferred time

Student Intern Name (if known)

Comments (optional)