Escape to Shanti COVID-19 Liability Waiver

Date of form completion*

Date of form completion

Date of appointment*

Date of appointment

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

Town / CityCounty

Postal Code

Phone Number*

Area codePhone Number

Do you have COVID-19?*

YesNo

I'm sorry to hear that. Please cancel your appointment with me, follow government guidelines, self-isolate, rest and recover. We'll get a replacement appointment in the diary. There will not be any penalty for cancelling your appointment.

Do you have any of the main symptoms of Coivd-19 including: A temperature, a new continuous cough, loss or change to your sense of smell or taste?*

YesNo

I'm sorry to hear that. Please cancel your appointment with me, follow government guidelines, self-isolate, rest and recover. We'll get a replacement appointment in the diary. There will not be any penalty for cancelling your appointment.

Do you have a new continuous cough?*

YesNo

I'm sorry to hear that. Please cancel your appointment with me, follow government guidelines, self-isolate, rest and recover. We'll get a replacement appointment in the diary. There will not be any penalty for cancelling your appointment.

Do you have any loss or change to your sense of smell or taste?*

YesNo

I'm sorry to thear that. Please cancel your appointment with me, follow government guidelines, self-isolate, rest and recover. We'll get a replacement appointment in the diary. There will not be any penalty for cancelling your appointment.

Are you experiencing any other symptoms of illness such as shortness of breath or difficulty breathing, fever , chills, repeated shaking with chills, muscle pain, headache, sore throat, diarrhoea, a skin rash, or discolouration of the fingers or toes.*

YesNo

I'm sorry to hear that. Please cancel your appointment with me, follow government guidelines, self-isolate, rest and recover. We'll get a replacement appointment in the diary. There will not be any penalty for cancelling your appointment.

Have you had COVID-19?*

YesNo

I'm sorry to hear that.

If you are fully recovered and fully fit to have complementary therapies, please come and enjoy your treatment as planned. It is adviseable to leave about 14 days after recovering from Covid-19 before having complementary therapies to allow your body to heal.

If you are not fully recovered or not fully fit, please cancel your appointment until you are fully fit. We''ll get another appointment in the diary. There will not be any penalty for cancelling your appointment.

If you are unsure, please contact your GP to check before continuing with this form or attending your appointment.

Does anyone in your household or support bubble have COVID-19 or symptoms of COVID-19?*

YesNo

I'm sorry to hear that. I hope they soon recover and everyone else stays well. Please cancel your appointment with me, follow government guidelines, and self-isolate as required. We'll get a replacement appointment in the diary. There will not be any penalty for cancelling your appointment.

Have you been contacted by the NHS Test, Track and Trace service and told to self-isolate?*

YesNo

I'm sorry to hear that. I hope you stay well. Please cancel your appointment with me, follow government guidelines, and self-isolate as required. We'll get a replacement appointment in the diary. There will not be any penalty for cancelling your appointment.

Have you travelled internationally or to a highly affected area of the UK within the last 14 days?*

YesNo

Please cancel your appointment with me, follow government guidelines, self-isolate if necessary. We'll get a replacement appointment in the diary. There will not be any penalty for cancelling your appointment.

Are you classed as an extremely vulnerable person (high risk)?*

YesNo

Have you got written consent from your GP/consultant/other medical professional to your having the treatment you have booked?

YesNo

Please bring a copy of their written consent with you to your appointment

Please cancel your appointment until you have obtained written consent from your GP/consultant/other medical professional to your having the treatment you have booked

Are you classed as a vulnerable person (moderate risk)?*

YesNo

Have you spoken to your GP/consultant and obtained their consent, either verbally or in writing, to your having the treatment you have booked?

YesNo

Please cancel your appointment until you have obtained consent, either written or verbal from your GP/consultant/other medical professional to your having the treatment you have booked

Please read the following waiver carefully and sign to accept that you fully understand and agree to all elements.

I acknowledge the contagious nature of the Coronavirus/COVID-19.

I further acknowledge that Margaret Webster, Holistic Therapist of Escape to Shanti has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.

I further acknowledge that Margaret Webster, Holistic Therapist of Escape to Shanti can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, the therapist, and other clients and their families.

I voluntarily seek services provided by Margaret Webster, Holistic Therapist of Escape to Shanti and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.

I confirm that the information provided above is correct and true to the best of my knoweldge.

I hereby release and agree to hold Margaret Webster, Holistic Therapist of Escape to Shanti harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the therapist or business, or that may otherwise arise in any way in connection with any services received from Margaret Wesbter, Holistic Therapist of Escape to Shanti. I understand that this release discharges Margaret Webster, Holistic Therapist of Escape to Shanti from any liability or claim that I, my heirs, or any personal representatives may have against the therapist or business with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Margaret Webster, Holistic Therapist of Escape to Shanti. This liability waiver and release extends to both the therapist and business.

Signature*

Escape to Shanti COVID-19 Information and Liability Waiver