Declaration: (please read this section carefully and sign below)
I, the undersigned, have completed this form as fully and accurately as I can. I believe the details to be correct and consent to having treatment
I have considered the risk of transmission of Coronavirus as a result of attending the clinic and would like to attend
I understand that Prime Wellbeing has taken reasonable steps to prevent Covid-19 transmission at the Clinic, but they cannot guarantee that this will not happen during my visit to the clinic.
GDPR: We are collecting and processing personal data on the basis of Art.6(1)(f) and Art.9(2)(i) Reg/n(EU)2016/679 (“GDPR”) being necessary for the purpose of the legitimate interests pursued by Prime Wellbeing Foundation, and to protect against threats to health, as a preventive measure to mitigate the risk of a Coronavirus (COVID-19). This data sheet will be stored confidentially and is not shared with any third party.