Pre-appointment Questionnaire

Join us “Saving Lives Together”

Dear patient,

Following the current Geneva Public Health protocols, AcuCentre is restricted from treating in its physical location active Covid-19 patients or potential carriers. If you suffer from or might suspect a Covid-19 infection, we offer distance consultations to prescribe medicinal herbs to help you strengthen your natural immunity, alleviate symptoms and help quickly recover. If you have symptoms, contact the Covid-19 hotline or your doctor. The form below will help us determine the best care and course of action for you and your family.

Please complete the form below. The fields followed by * are required.

Name

First Name

Last Name

Phone

(###)

###

####

Temperature

If you feel feverish, please take your temperature and record it in the space below:

Common Covid-19 symptoms are cough, fever, difficulty breathing, loss of smell and /or taste, flu-like joint pains. Please check all that apply

I have a cough

I have fever

I have difficulty breathing

I have no sense of smell and/ or taste

I suffer from flu-like joint pains

I have been in contact with someone suffering or suspected of suffering from Covid-19 during the past 2 weeks

I have no cough, no fever, no difficulty breathing, no loss of smell and /or taste, nor flu-like joint pains and have no known Covid-19 symptoms.

Your comments on any checked box

Pre-appointment questionnaire

Pre-appointment Questionnaire

Please complete the form below. The fields followed by * are required.

AcuCentre