Dublin Reflexology Pre-Health Screening COVID-19 Questionnaire
To help prevent the spread of the COVID-19 and reduce the potential risk of exposure to all my clients, I am conducting a simple screening questionnaire prior to attending my consulting room. Your participation is important to help me protect you and everyone as much as is possible on my premises. Thank you in advance for your time.
Full Name
*
First Name
Last Name
Email
*
example@example.com
Mobile Phone Number
*
Format: (000) 000-0000.
Have you any symptoms of coronavirus, runny nose, cough, breathing difficulties, sore throat, fever, or vomiting?
Yes
No
Have you or any family members, or members of your household travelled abroad in past 14 days?
*
Yes
No
If YES above, what country have you travelled to /from?
If travel related testing is necessary please await result before booking.
PLEASE ALSO ONLY BOOK AN APPOINTMENT FOR AT LEAST 5 DAYS AFTER RETURNING FROM ANY FOREIGN TRAVEL
As current guidelines suggest, it takes 2- 14 days for symptoms to appear, so I as your therapist have put a number of procedures in place to limit, as much as possible, the transmission of the virus
I understand that there is a risk of contacting Covid-19 as a result of attending, through no fault of my therapist
Yes
No
I agree that Ruth Wallace cannot accept responsibility or liability for the transmission of Covid-19, should I become infected.
Yes
No
Are you currently taking any medication?
*
Yes
No
If any symptoms change I will contact Ruth immediately
*
Yes
No
Privacy Policy:
This questionnaire must be completed at time of booking, and signed on arrival if not done in advance. I will be holding on file for a minimum of 2 months, and will also be retaining details of your appointment time duration and contact number for Contact tracing should it be required by HSE.
Join our Newsletter?
*
Yes
No
Signature
By submitting this form I am agreeing to the terms and conditions above.
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