COVID - 19 Consent Form (FACE TO FACE only)

I acknowledge the contagious nature of the Coronavirus/COVID-19 and the World Health Organisation [WHO] and many other public health authorities still recommend practicing social distancing. I also acknowledge that Pilates with Esther has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19, as per this guidance. I further acknowledge that Esther Fransham cannot guarantee that I will not become infected with the Coronavirus/COVID-19

I voluntarily seek services by Pilates with Esther and I acknowledge that I must comply with all set procedures to reduce the spread while attending my class.

All persons who have completed the Covid-19 Screening Form should read and sign the following disclaimer. I will answer all questions truthfully and to the best of my knowledge. If there are any changes in my physical or medical health I will inform Esther Fransham of Pilates with Esther as soon as possible and before any sessions. I am responsible for checking with my GP to ensure I am able to participate in any physical activities.

By signing this document I state that I have been screened for COVID-19 and confirm that should I answer yes to any questions I may be asked to seek medical advice before I can attend the class.

Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Have you displayed any signs or symptoms of COVID-19 in last 2 weeks or been in contact with anyone who has displayed symptoms of COVID-19 Y/N *

Yes No

Have you returned back from abroad to UK in last 2 weeks Y/N *

Yes No

In the last 24hrs have you had any of following symptoms? High temperature? Sore throat? New or worsening cough? Nausea/vomiting/diarrhoea? Y/N *

Yes No

To prevent the spread of this contagious virus and to help protect each other, I understand that I will *

I will adhere to strict social distancing rules whilst I am in class I will not come to class if I feel unwell I will provide all my own equipment

I understand, read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that this document is to provide the safest class possible. *

By checking this box I understand this statement

Signature

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Date

Please verify that you are human *