COVID-19 SCREENING & DISCLAIMER FORM

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? *

Yes No
If no, please move to Covid-19 Screen and disclaimer form below
Were you tested to confirm this diagnosis?

Yes No
What date were you tested/diagnosed?
Were you hospitalised, requiring oxygen?

Yes No
Were you in ICU?

Yes No
Did you require mechanical ventilation?

Yes No
How long were you in ICU for?
When were you discharged?
Do you still have any symptoms of Covid19??

Yes No
Has a test confirmed you are now negative and thus free of Covid-19?

Yes No
Have you been left with any lasting health restrictions such as shortness of breath, fatigue or difficulty lying down due to chest issues?

Yes No
Have you been put on blood thinners such as Warfarin?

Yes No
Do you consider yourself back to full health?

Yes No
How would you best describe your health?
COVID-19 SCREENING & DISCLAIMER FORM
Are you currently experiencing ANY of the following symptoms?
A high temperature or fever? *

Yes No
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. *

Yes No
A loss of, or change in sense of smell or taste? *

Yes No
Shortness of breath and/or having any breathing difficulties? *

Yes No
A sore throat, congestion or a runny nose? *

Yes No
Rashes particularly on your feet? *

Yes No
Inability to wake and stay awake? *

Yes No
Unexplained nausea or vomiting? *

Yes No
Unexplained diarrhoea? *

Yes No
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.
Are you at high risk from Covid-19 and shielding?
Having cancer treatments that lower the immune system?(e.g. chemotherapy, radiotherapy, immunotherapy, bone marrow or stem cell transplant) *

Yes No
Organ transplant or taking immune suppressants? *

Yes No
Have a severe respiratory condition? (e.g. cystic fibrosis, severe asthma, COPD) *

Yes No
Have a serious heart condition? *

Yes No
Are you clinically vulnerable or shielding someone who is vulnerable? *

Yes No
Are you 70 years or older? *

Yes No
Have a respiratory condition? (e.g. asthma, COPD, emphysema or bronchitis) *

Yes No
Have type 1 or type 2 diabetes? *

Yes No
Have heart disease? (e.g. heart failure, high blood pressure) *

Yes No
Have chronic kidney and/or liver disease? *

Yes No
Have compromised immune system and are at risk of infection? *

Yes No
Have a neurological condition? (Parkinson's Disease, Motor Neurone Disease, Multiple Sclerosis or Cerebral Palsy) *

Yes No
Currently pregnant? *

Yes No
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.
COVID-19 SCREENING & DISCLAIMER FORM

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

Yes No
If answered yes, please give details:
Have you travelled abroad in the last 14 days? *

Yes No
If answered yes, please give details:
Are you an NHS front line worker? *

Yes No
Are you a Carer, either at home or in a Care Home? *

Yes No
Are you allergic to any cleaning fluids? *

Yes No
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? *

Yes No
Signature *

Clear
Date *

Month Day Year
Date
I (Clients name) .First Name* Last Name*

I Confirm:
- within the last 14 days, I have not been diagnosed with C ovid - 19 , nor have I experienced any Co vid - 19 symptoms;
- to the best of my knowledge, within the last 14 days no member of my household has been diagnosed with Co vid - 19 , nor have they experienced any Co vid - 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 Co vid - 19 or experiencing Co vid - 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.
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COVID-19 SCREENING & DISCLAIMER FORM

COVID-19 SCREENING & DISCLAIMER FORM

Are you at high risk from Covid-19 and shielding?

COVID-19 SCREENING & DISCLAIMER FORM