Pre-treatment Form for Advantage Aromatherapy

Advantage Aromatherapy Returning Client Pre-treatment Form.

For all of our safety, please fill in this short form & return it as soon as possible prior to your treatment (& each treatment until further notice). Be sure that the information you give is accurate and complete. Please get immediate medical attention if you have any of the severe COVID-19 symptoms. NOTE: Your information will be kept in line with test & protect regulations.
Please fill out all fields marked with an asterix*
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number

In the past 14 days, have you experienced any of the following? Please note that a selection is required for each row.*

	Yes	No
Fever 37.8°c
Unexplained body aches or pain
Coughing
Sore throat
Shortness of breath
Chills with or without body aches
Recent loss of sense of smell or taste
Unexplained sores on soles of feet
Unusual fatigue
Non-allergy related runny nose

Do you have any secondary health issues that place you in the high risk or moderate risk categories? (pregnancy, 70 or older, lung conditions, heart disease, diabetes, kidney disease, liver disease, lower immune system through medication or BMI of 40 or above)*

YesNo
If you answered yes, then please detail conditions below
Please contact us prior to your treatment if you have any questions or concerns relating to secondary health issues.
Have there been any changes to your medical circumstances since your last appointment.*

No changes to my health since my last appointment.Yes there have been changes
Please inform us of any changes to your health here
Please note: It is your responsibility and not that of the therapist to consult your GP or Consultant.
I, Janice Evans of Advantage Aromatherapy state that I am currently free from symptoms of Covid-19 and have not been in contact with anyone suffering Covid-19 or with anyone who is in isolation. I also state that I have observed all the safety regulations from the Scottish Government pertaining to Covid-19 and the safe return to work in line with close contact services. If I develop any symptoms I will call to cancel and/or re-schedule immediately.
Finally, how would you prefer to pay for your treatment? Please note that cashless payments are preferable due to covid-19.

Bank Transfer (must be done before treatment)Mobile payment via text (must be done before treatment)Over the phone card payment (must be done before treatment)With my card (after treatment with card machine)Cash (after the treatment)
Signature*

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Advantage Aromatherapy Returning Client Pre-treatment Form.