Client Consent Form

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Client Consent Form - COVID-19

Please answer the questions below, this is designed to minimise risk to me, your practitioner and you my client before treatment. This form will be used in addition to taking your usual client medical history in which details of any changes in health/wellbeing are noted. Your data is held in compliance with the GDPR policy of my practice held on secure Google servers.

Your name: *

Your telephone number: *

1. Have you tested positive or had treatment for COVID-19? *

YES

2. Have you, or has anyone you are in close contact with, had any of the following signs or symptoms associated with coronavirus? Tick if you or someone you’ve come into contact with, has experienced any of the following symptoms: *

A high temperature – this means you feel hot to touch on your chest or back (you do not need to measure your temperature)

A new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual)

A loss or change to your sense of smell or taste – this means you've noticed you cannot smell or taste anything, or things smell or taste different to normal

Tick if none of the above applies

Required

3. If you ticked any of the questions above, please indicate when you or someone you know had the coronavirus symptoms

4. Tick to confirm you’ve strictly followed the social distancing measures outlined by the government during COVID-19? *

YES

Required

5. When you checked your temperature prior to attending this treatment was it within the normal range of 36.1°C - 37.2°C *

YES

I consent to treatment from Sarah Holder. I confirm I am in agreement to the necessary adaptations required to treatments before and during sessions as well as to the suspension of social distancing measure. I understand that these adaptations help to reduce the risk of Coronavirus but cannot eradicate it. I also confirm that I understand that receiving treatment may increase my risk of exposure to Coronavirus. Please sign below to agree.

Signed: *

Date: *

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