Covid-19 Screening

Please complete the form below

Name

First Name

Last Name

Contact Phone Number

Date of Birth

Name and address of GP

Covid-19 Screening when making the appointment.

If numbers 3 and 4 apply to you, treatment can only proceed once GP approval has been granted.

1. I have been tested for Covid-19

2. I have previously tested positive for Covid-19

3. Having tested positive, I was hospitalised

4. I am currently taking medication for Covid-19

Not applicable

5. Have you or any of your household been contacted by the Test and Trace Team and advised to self isolate?

If YES, the treatment can only take place once the period of self-isolation has been completed.

Do you or any members of your household currently have any of the symptoms of Covid-19?

If the answer is YES to any of these than treatment cannot commence until an isolation period in line with Government Guidance has been completed and you can confirm you are symptom-free.

High temperature

New, continuous cough

Loss or change to sense of smell or taste

None of these

Consent Declaration for Face-to-Face Appointments during Covid-19

The information I have given in this form is honest, accurate and correct to the best of my knowledge. I have had the opportunity to ask all the questions about its content and all of my questions have been answered to my satisfaction. I appreciate that although all reasonable steps to reduce risk of infections have been taken, including screening all potential Covid-19 cases and undertaking increased hygiene and distancing protocols, there may still be a risk of infection from Face-to-Face treatment. I knowingly and willingly consent for Face-to-Face treatment to take place. I understand I can read about Neuromassage Therapies' data protection policy here: www.neuromassagetherapies.com/privacy

Date

YYYY

Covid-19 Screening

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Hours

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