COVID

FOR YOUR SAFETY

Due to the 2019-2021 outbreak of the novel coronavirus, COVID-19, we are taking extra precautions with the intake of each client, health history reviews, as well as sanitation and disinfecting practices. Please complete the form below.

PRECAUTIONARY CORONAVIRUS LIABILITY RELEASE FORM

Symptoms of COVID-19 include:

High Temperature / Fever
Fatigue
New continuous dry cough
Difficulty breathing
Loss or change to your sense of smell or taste

If you currently have symptoms of COVID-19 but have not yet used the NHS 111 online coronavirus service, please do

so. If you have any other new or unusual symptoms, please discuss these with your therapist before your appointment

PRECAUTIONARY CORONAVIRUS LIABILITY RELEASE FORM

full name

agree to

agree to the following:

clause #1

I understand the above symptoms and affirm that I, as well as all household members to not currently have, nor have experienced the symptoms listed above within the last 14 days

Please defer text:

Please defer your treatment if you: are waiting for a COVID-19 test result; have recently tested positive for COVID-19; or have a high temperature, new continuous cough, or a loss or change to your sense of smell or taste. If you currently have symptoms of COVID-19 but have not yet used the NHS 111 online coronavirus service, please do so. If you have any other new or unusual symptoms, please discuss these with your therapist before your appointment

Have you had COVID-19?

Yes I have had Covid-19

No I have not had Covid-19

Covid positive text:

If you have had COVID-19, please seek consent from your GP or consultant before treatment.

Are you classed as an extremely vulnerable person (high risk)?

Yes I'm classed as an extremely vulnerable person

No I'm not classed as an extremely vulnerable person

If you are vunerable Text:

If you are classed as clinically extremely vulnerable and require shielding, you will have received a letter from the NHS explaining this. Defer treatments until the government indicates that it is safe for you to leave home or have visitors providing non-essential care.

clause #2

I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days

Have you been in close contact with anyone else in the past 14 days who has symptoms of COVID-19, or been contacted by the NHS Test and Trace service and told to self-isolate? If yes, please defer seeing your therapist until it is safe to do so.

Yes

clause #3

I affirm that I, as well as all household members, have not travelled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections in the last 30 days

clause #4

I understand that this business and my massage therapist cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client

By signing

Unlike people at high risk, those who are classed as clinically vulnerable will not have received a letter from the NHS. If you are unsure if you are clinically vulnerable, please refer to the NHS website at www.nhs.uk . If you meet the definition of someone who is clinically vulnerable, please discuss this further with your therapist and seek consent from your GP, midwife or consultant before having a treatment.

Please check your temperature on the morning of your treatment. If it is higher than usual, or if you have any other symptoms, please contact your therapist to defer your treatment. Please ensure that you follow all new procedures explained to you by your therapist, prior to treatment.

Your therapist has carried out a full risk assessment and adheres to COVID-19 guidelines produced by the government and their professional association, the Federation of Holistic Therapists (FHT). For more information, visit fht.org.uk/coronavirus

By signing below, I agree to each above statement and release the massage therapist and business from any and all liability for the unintentional exposure or harm due to COVID-19.

Your massage

Your massage therapist from Fylde Holistic Therapies has agreed to abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to fight the spread of COVID-19 and other communicable conditions more thoroughly.

Signature

Date

Phone

Thank you for signing this form as an extra precaution for us both during these times, it will be added to your file.

Oops, there was an error signing your form.

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AREAS COVERED

Mobile Holistic Therapy treatments for the Fylde Coast (FY postcodes only) area, Lancashire, North West, UK

fyldeholistictherapies@outlook.com

OPENING HOURS

Mon - Thu: 9:00 am - 4:00 pm
Fri - Sun: Closed