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Covid-19 Client Questionnaire/Declaration

Thank you for filling out our consultation form. Please take a moment to fill out our COVID-19 client questionnaire.

My priority at this time is to keep both clients and myself as safe as possible. In order to achieve this, I have taken measures in line with the current Coronavirus government guidelines and are duty-bound to ask you the following set of questions. I assure you that the information you give remains confidential unless legally bound to release it. Thank you for your support.

Full Name

Address

Telephone Number

Date of Birth

Are you currently experiencing any symptoms of COVID-19? Are you currently experiencing any symptoms of COVID-19? Yes No

Are you experiencing any of the following symptoms which have suddenly become apparent (tick those that apply)? Are you experiencing any of the following symptoms which have suddenly become apparent (tick those that apply)? Difficulty Breathing Loss of Taste and/or Smell Fever Persistant Dry Cough

Is anyone in your household experiencing any symptoms of COVID-19? Is anyone in your household experiencing any symptoms of COVID-19? Yes No

Have you been in contact with anyone else with any COVID-19 symptoms in the last 7 days? Have you been in contact with anyone else with any COVID-19 symptoms in the last 7 days? Yes No

Have you returned from travelling abroad in the last 14 days? Have you returned from travelling abroad in the last 14 days? Yes No

If yes, when and where

Please note that I am obliged to notify NHS track and trace if circumstances require such. if I report any symptoms among clients or myself, or I am contacted by Track and Trace, I am legally obliged to provide them with your contact details and you may be contacted. Please note that I am obliged to notify NHS track and trace if circumstances require such. if I report any symptoms among clients or myself, or I am contacted by Track and Trace, I am legally obliged to provide them with your contact details and you may be contacted. I understand

Do you promise to contact me immediately if you or anyone in your household develops symptoms, associated with COVID-19 within 7 days after your treatment Do you promise to contact me immediately if you or anyone in your household develops symptoms, associated with COVID-19 within 7 days after your treatment I Promise

If anything changes between now and your appointment time, do you promise to inform me before your appointment date? If anything changes between now and your appointment time, do you promise to inform me before your appointment date? I Promise

7 + 5 =

The Hidden Sanctuary

Holistic Therapies by Lucy

Reflexology, Massage, Reiki & Crystal bespoke holistic treatments to suit you.

Fully qualified and insured holistic therapist.

Member of the Federation of Holistic Therapists.