Premises Agreement Form

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Please tick below boxes to agree and sign and date below. Thank you for your co-operation.

While on the premises of either treatment venue, I agree to: *

Maintain a 2 metre distance from other people whenever possible

Wear a face mask/ gloves if my practitioner directs me to and not remove the mask/gloves except when directed by staff

Wash my hands for 20 seconds (or use a hand sanitiser if washing facilities not available) before and after my treatment, before and after using the bathroom, and to maintain hand hygiene at other times by washing hands correctly

Practice proper cough & sneeze etiquette by coughing/sneezing into tissues, washing hands, disposing of tissues as instructed. I agree that if I am about to cough or sneeze, I will warn my practitioner so that they can maintain a safe distance

Remain in areas designated for my visit only

I agree to immediately notify Sarah Holder if I develop symptoms of COVID-19 within fourteen (14) days of my last visit

Required

Signed: *

Date: *

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