COVID-19 CONSENT FORM

Our Covid-19 online consent form must be completed 48 hours before your scheduled appointment with us.  Our clients & therapist safety is of the utmost importance to us.

    Have you had a high temperature or fever in the last 7 days?
    YesNo

    Are you now, or have you recently had, a persistent dry cough? A new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours
    YesNo

    Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has coronavirus-type symptoms?
    YesNo

    Have you been told to stay home, self-isolate or self-quarantine?
    YesNo

    Have you noticed a loss or change to your sense of smell or taste – this means you've noticed you cannot smell or taste anything, or things smell or taste different to normal
    YesNo

    Have you tested positive or had treatment for COVID-19?
    YesNo

    Have you travelled outside of the UK in the last 21 days? Have you travelled from an area in the UK under current lockdown restrictions and if so where, and have you fulfilled the legal obligation to quarantine for 14 days?
    YesNo

    High Risk Clients (clinically extremely vulnerable) - Please tick if any of the following apply to you
    Received an organ transplantReceiving chemotherapy or antibody treatment for cancer, including immunotherapyReceiving an intense course of radiotherapy (radical radiotherapy) for lung cancerHaving targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors)Have blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma)Had a bone marrow or stem cell transplant in the past 6 months, or still taking immunosuppressant medicineDiagnosed severe lung conditions (such as cystic fibrosis, severe asthma or severe COPD)Have a condition that means you have a very high risk of getting infections (such as SCID or sickle cell) taking medicine that makes you much more likely to get infections (such as high doses of steroids)Pregnant and have a serious heart conditionNone of the above

    If you have ticked any of these boxes after reading this list, you are classed as extremely vulnerable and the government advise that you exercise ‘shielding’. We will need a referral letter from your doctor to be able to offer you a treatment.

    Moderate Risk Clients - Please tick if any of the following apply to you:
    70 or olderPregnantHave a lung condition that is not severe (such as asthma, COPD, emphysema or bronchitis)Have heart disease (such as heart failure)Have diabetesHave chronic kidney diseaseHave liver disease (such as hepatitis)Have a condition affecting the brain or nerves (such as Parkinson's disease, motor neurone disease, multiple sclerosis or cerebral palsy)Have a condition that means you have a high risk of getting infectionsTaking medicine that can affect the immune system (such as low doses of steroids)Very obese (BMI of 40 or above)None of the above

    After reading the above, if you have ticked any of the boxes, you are at moderate risk from coronavirus and it is very important you follow the advice on social distancing.

    Have you received a vaccine for COVID-19

    YesNo

    1st Vaccine date

    2nd Vaccine date

    I give consent for receiving a treatment/s with a therapist Every Body Therapy.

    I declare that the information I have provided is correct to the best of my knowledge and I understand that, that my treatment or experience may involve close contact touch over a period of time, there may be a raised risk of disease transmission, including Covid-19.

    I give consent to the therapist/stylist retaining the details provided on this form for a period of 7 years from today. (standard procedure) I further understand that if I am under 18 years of age*, these records will be kept until I reach the age of 25 (7 years after reaching 18).

    I give my consent to receive treatment or experience from Charlotte Every from Every Body Therapy