COVID-19 SCREENING & DISCLAIMER FORM

For the health and safety of myself and my clients, I am implementing additional measures in compliance with the precautions published by both the UK and Scottish Governments in

respect of the disease known as coronavirus disease (COVID-19) and the virus known as Severe Acute Respiratory syndrome coronavirus 2 (SARS-CoV-2) (“Coronavirus”)

To the best of my knowledge, I (Independent therapist) do not have Covid-19, nor have I been in contact with anyone with Covid-19, or anyone displaying any symptoms of Covid-19. If this changes, and either I or one of my clients test positive, I will inform you immediately and we will both self-isolate for 7 days or until I know it is safe for me to return to work in accordance with the Scottish/UK Government Covid-19 Guidelines.

Clients full name*

Address and Postcode*

Contact number*

Since January 2020, have you had Covid-19?*

YesNo

If no, please move to Covid-19 Screen and disclaimer form below

Were you tested to confirm this diagnosis?

YesNo

What date were you tested/diagnosed?

Were you hospitalised, requiring oxygen?

YesNo

Were you in ICU?

YesNo

Did you require mechanical ventilation?

YesNo

How long were you in ICU for?

When were you discharged?

Do you still have any symptoms of Covid19??

YesNo

Has a test confirmed you are now negative and thus free of Covid-19?

YesNo

Have you been left with any lasting health restrictions such as shortness of breath, fatigue or difficulty lying down due to chest issues?

YesNo

Have you been put on blood thinners such as Warfarin?

YesNo

Do you consider yourself back to full health?

YesNo

How would you best describe your health?

Are you currently experiencing ANY of the following symptoms?

A high temperature or fever?*

YesNo

A new continuous cough? (Coughing for longer than an hour, or three or more coughing episodes in 24 hours. If you usually have a cough, it may be worse than usual.*

YesNo

A loss of, or change in sense of smell or taste?*

YesNo

Shortness of breath and/or having any breathing difficulties?*

YesNo

A sore throat, congestion or a runny nose?*

YesNo

Rashes particularly on your feet?*

YesNo

Inability to wake and stay awake?*

YesNo

Unexplained nausea or vomiting?*

YesNo

Unexplained diarrhoea?*

YesNo

If you have answered yes to any of the above questions.

I cannot treat you at this time. Please isolate yourself and your family for 14 days, until all the symptoms have gone. Contact your GP for advice and ask to be tested to confirm Covid-19.

Please complete form and Intercity will contact you shortly.

Having cancer treatments that lower the immune system?(e.g. chemotherapy, radiotherapy, immunotherapy, bone marrow or stem cell transplant)*

YesNo

Organ transplant or taking immune suppressants?*

YesNo

Have a severe respiratory condition? (e.g. cystic fibrosis, severe asthma, COPD)*

YesNo

Have a serious heart condition?*

YesNo

Are you clinically vulnerable or shielding someone who is vulnerable?*

YesNo

Are you 70 years or older?*

YesNo

Have a respiratory condition? (e.g. asthma, COPD, emphysema or bronchitis)*

YesNo

Have type 1 or type 2 diabetes?*

YesNo

Have heart disease? (e.g. heart failure, high blood pressure)*

YesNo

Have chronic kidney and/or liver disease?*

YesNo

Have compromised immune system and are at risk of infection?*

YesNo

Have a neurological condition? (Parkinson's Disease, Motor Neurone Disease, Multiple Sclerosis or Cerebral Palsy)*

YesNo

Currently pregnant?*

YesNo

If pregnant, how many weeks?

If answered yes to any of above questions, You are high risk or vulnerable.

As you are at high risk / vulnerable from Covid-19, I am unable to treat you at this time. Once shielding is reduced, please contact me to rebook your treatment.

Please complete form and Intercity will contact you shortly.

Do you have any other medical condition which makes you a higher risk to the effects of Covid-19?*

YesNo

If answered yes, please give details:

Have you travelled abroad in the last 14 days?*

YesNo

If answered yes, please give details:

Are you an NHS front line worker?*

YesNo

Are you a Carer, either at home or in a Care Home?*

YesNo

Are you allergic to any cleaning fluids?*

YesNo

If answered yes, please give details:

Do you consent to me informing NHS Scotland Test & Protect of your details if either you or I find out we are infected?*

YesNo

Signature*

Date*

Date

I (Clients name) .First Name* Last Name*

I Confirm:

within the last 14 days, I have not been diagnosed with Covid-19, nor have I experienced any Covid-19 symptoms;
to the best of my knowledge, within the last 14 days no member of my household has been diagnosed with Covid-19, nor have they experienced any Covid-19 symptoms;to the best of my knowledge, within the last 14 days neither myself nor any other member of my household have been exposed to anyone diagnosed with Covid-19 or experiencing Covid-19 symptoms.

By signing this document, I confirm the above statements are true and correct.

I hereby acknowledge that massage services involve close contact with a Massage Therapist for a period and in circumstances in which it is possible to contract Covid-19, notwithstanding any safety measures and precautions to the contrary. I agree to accept this risk in order to receive the benefit of the massage services. I hereby irrevocably and unconditionally waive all claims and release and forever discharge

Independent Therapist / Intercity mobile therapists Ltd and its officers, directors, and employees from all and any liability whatsoever in relation to any claim for any death, injury, loss, or damage of whatsoever nature, that may arise if I contract Coronavirus in the provision of the services or infect another person, except in so far as it can be demonstrated that such death or injury was occasioned as a result of Independent therapist / Intercity mobile therapists Ltd negligence or failure to take appropriate safety measures and precautions. Nothing in this document excludes or limits any liability which cannot legally be limited, including but not limited to liability for death or personal injury caused by negligence.