Aloha Massage's COVID-19 Pre-Treatment Questions

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Please complete and submit this form before your treatment. Ideally no more than 24 hours before. Please contact us if you have any questions. adele@alohamassage.co.uk 07792136428 Thank you.
For full information about the steps we are taking in light of COVID-19 visit http://www.alohamassage.co.uk/covid-19-policy.html

Email *

Full Name *

Contact Number *

Treatment Date

YYYY

Do you currently have COVID-19 or any symptoms of COVID-19? *

Please defer your treatment if you: Are waiting for a COVID-19 test result; have recently tested positive for COVID-19; or have a high temperature, new continuous cough, or loss or change to your sense of smell or taste. If you currently have symptoms of COVID-19 but have not yet used NHS 111 Online Coronavirus Service, please do so. If you have any other new or unusual symptoms, please discuss these with us before your appointment.

Yes

Have you previously had COVID-19? *

If yes, please give details of when and the severity. If you have had COVID-19 please seek consent from your GP or Consultant before treatment.

Does anyone in your household have COVID-19 or symptoms of COVID-19? *

If yes , please defer your treatment until it is safe to do so.

Yes

Have you been in close contact with anyone else in the past 14 days who has symptoms of COVID-19, or been contacted by NHS Test and Trace Service (including the App) and told to self isolate? *

If yes , please defer your treatment until it is safe to do so.

Yes

Have you had any Covid Vaccinations?

This question is optional.

Have you recently taken a Covid-19 Test? lateral flow or PCR

If Yes, please state the date and result, thank you. This question is optional.

Have you recently returned from travelling abroad? *

If yes please state location and return date.

Are you classed as a 'extremely vulnerable' person (high risk)? *

If you are classed as 'clinically extremely vulnerable' and require shielding, you will have received a letter from the NHS explaining this. Defer treatments until the Government indicates that it is safe for you to leave home or have visiting providing non-essential care.

Yes

In light of all the changes and restrictions due to COVID-19, do you have any concerns or hesitations that you would like to discuss before your treatment?

I, the named person above confirm that:

I have read, understood and completed this form truthfully and to the best of my knowledge.

I understand if I am feeling unwell or have been told to self isolate, I will not attend the appointment and inform Adele

I give my permission for Aloha Massage to give my details to NHS Track and Trace if needed.

I understand that I am requested to wear a face covering at my appointment unless I am exempt.

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