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Client Consent Form - COVID-19
Please fill out and complete this COVID-19 form before your Shiatsu treatment. It 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 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.
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Contact Telephone Number
*
Your answer
Have you tested positive or had treatment for COVID-19?
*
Yes
No
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 to confirm you’ve strictly followed the social distancing measures outlined by the government during COVID-19?
*
Yes
No
When you checked your temperature prior to attending this treatment was it within the normal range of 36.1°C - 37.2°C
*
Yes
No
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