H SUSAN GARDNER PT

Train from anywhere in the World with your own PT

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Last Name

Date of Birth

Have you been hospitalized in the last 12 months?

No

Yes

Are you currently suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

How are you feeling today?

First Name

Last Name

Email

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat

I haven’t been in close contact with a Covid-19 patient in the last 14 days

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

First Name

Last Name

Email

Phone

Rate Our Services

Excellent

Good

Disappointing

What did you like best?

How can we improve?

Would you recommend us to your friends?

Yes

No

Anything else you would like to add?

Thanks for submitting!

07962 532 231