Escape to Shanti COVID-19 Liability Waiver

Date of form completion *

Date of form completion

Date of appointment *

Date of appointment

Name *

First Name Last Name

Email *

example@example.com

Address *

Street Address

Street Address Line 2

Town / City County

Postal Code

Phone Number *

Area code Phone Number

Do you have COVID-19? *

Yes No

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 temperature of 38 degrees or more? *

Yes No

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? *

Yes No

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? *

Yes No

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. *

Yes No

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? *

Yes No

I'm sorry to hear that.

If you are fully recovered and have been given the 'all-clear' by a medical professional to have complementary therapies, please come and enjoy your treatment as planned.

If you are not fully recovered or have not been given the 'all-clear', please cancel your appointment until you are fully fit and a medical professional tells you it is ok for you to have complementary therapies. 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? *

Yes No

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 in close contact with anyone else in the last 14 days who has symptoms of COVID-19 or been contacted by the NHS Test, Track and Trace service and told to self-isolate? *

Yes No

I'm sorry to hear that. I hope they soon recover and 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? *

Yes No

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)? *

Yes No

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

Yes No

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)? *

Yes No

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

Yes No

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 *

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Escape to Shanti COVID-19 Information and Liability Waiver