Covid-19 Consent Form
Due to the outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Please fill out the COVID-19 consultation forms and the treatment you will be having in the salon. You will need to fill out a consultation form only once unless there has been any changes to the last form you filled out. Your therapist will confirm with you that nothing has changed before going ahead with your appointment.
Name
*
First Name
Last Name
Date of Birth:
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Day
-
Month
Year
Date
Phone Number
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Area Code
Phone Number
Mobile Number
Please enter a valid phone number.
Covid-19 Questions
Please answer the following questions as accurately as possible and answer all questions to assist your therapist in carrying out a safe and effective treatment.
Have you felt unwell in the last two weeks?
*
Yes
No
Do you have a fever? ( 37.5 degrees or above)
*
Yes
No
Do you have a new, persistent cough?
*
Yes
No
Do you have a sore throat?
*
Yes
No
Have you lost your sense of smell or taste?
*
Yes
No
Have you been in contact with someone who has any of these symptoms?
*
Yes
No
Have you travelled to an area at high risk for COVID-19 nationally or internationally?
*
Yes
No
Do you work in a hospital/care home or healthcare facility?
*
Yes
No
Have you recently been in contact with somebody who has been diagnosed with COVID-19 or has symptoms?
*
Yes
No
Have you been diagnosed with COVID-19 in the last 4 weeks?
*
Yes
No
Do you currently live in a household with somebody who has been diagnosed with COVID-19 or has symptoms?
*
Yes
No
I knowingly and willingly accept to have services performed by my therapist during the COVID-19 pandemic and agree that my therapist is not responsible for risks associated with receiving treatments during the COVID-19 pandemic. I understand and accept that I will be required to adhere to measures to restrict the transmission of COVID-19. I understand that COVID-19 has a long incubation period with some carriers not showing symptoms, but will still be highly contagious. I will be required to adhere to my therapists hygiene policy. I will adhere to any instructions from my therapist regarding social distancing during the appointment.
*
Yes
I can confirm that I have completed this form to the best of my knowledge and understand that if there are any changes, I will make my therapist aware before another treatment is carried out.
*
Yes
I understand that my temperature will the taken on arrival and that I may be refused entry if the result is above 37.7 degrees.
*
Yes
Date
*
-
Day
-
Month
Year
Date
Submit
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