Pre-Treatment Form

Please fill out this form and submit on the day of your treatment.


    Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? YesNo

    Have you been in close contact with a confirmed or suspected case of COVID-19 in the last 14 days? YesNo

    Are you awaiting results from a COVID-19 test? YesNo

    Have you had any of the following symptoms in the past 14 days?:

    • Cough
    • Fever
    • High Temperature
    • Sore Throat
    • Runny Nose
    • Breathlessness
    • Flu like symptoms
    • Abdominal Cramping
    • Diarrhoea
    • Loss of Taste or Smell


    Have you been advised by a Doctor or the HSE to self-isolate due to COVID-19? YesNo

    Have you been advised by a Doctor or the HSE to cocoon due to COVID-19? YesNo

    Could you be classified as a person falling into the “at risk” Group around whom additional HSE guidelines apply? YesNo

    I understand that this information is required for the purposes of public health and will be kept on file for a 2 month period from the date of signing.

    I confirm that the above information is true and accurate from the date of signing.

    I understand that my personal information including my name and contact details may be shared with the Health Service Executive (HSE) for the sole purpose of contact tracing in line with public health guidelines only if requested.

    I consent to being treated, and accept that should I become infected, Sakara House cannot be held liable for transmission of COVID-19.


    Treatment Procedure

    • Where possible please travel to the treatment alone in your car.
    • Please bring your own water, tissues, pen, face mask, gloves and any other PPE you wish.
    • For hygiene reasons, please wear socks.
    • There is no waiting room, please wait in your car until the practitioner calls you in.
    • There is a 15 minute gap between clients to allow for cleaning
    • On entry you must have completed this pre consultation form, on paper, online or over the phone
    • On entry your temperature will be taken and logged