Little Therapy Space
COVID - 19 Form
On the day of your appointment:
1.
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Please call and reschedule your appointment if you are experiencing any flu-like symptoms, or develop any within now and your appointment date/time.
2.
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When you enter the clinic, it is recommended that you put on a mask and sanitise or wash your hands. Please bring a mask from home if you have one.
4.
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You are asked to attend your appointments unaccompanied.
Please bring your own water with you if possible, which I can refill
5.
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My current 24 hour cancellation policy will be relaxed for now.
6.
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Please arrive on time as I’m having to keep to set times now. If you are early, please wait outside until 5 minutes before your session time. This allows a client to leave, me to clean and prepare for your arrival. If you are late,I will have to stop on time. Guidance currently is 60 minutes max in the room, so be prepared to get on the massage table as soon as you enter. Talking sadly is to be kept to a minimum.
Risk Assessment
Screening questionnaire
Have you or anyone in your household been diagnosed with COVID- 19?
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Yes
No
Other
Have you or anyone in your household been advised by the Government as being clinically vulnerable and to shield?
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Yes
No
Do you or a member of your household have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose?
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Yes
No
Have you been abroad in the past 14 days?
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Yes
No
Have you noticed a new rash on your legs/feet or body?
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Yes
No
Have you noticed any unusual leg cramping?
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Yes
No
Did you have close contact with a person who has a probable or confirmed case of COVID-19?
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Yes
No
Client Name
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First Name
Last Name
Parent/Guardian (If client is under 18 years of age)
First Name
Last Name
Contact number
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Emergency contact and contact details
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Submit
Should be Empty: