Pre-Covid Consultation Form

To help prevent the spread of COVID-19 in my treatment room and local community, I ask each client to complete and sign this form before attending for treatment.

On review of the form, I may contact you to ask you not to attend for your treatment at this time and will discuss a suitable future appointment.

N.B. Every question must be answered.
I have taken extra measures to safeguard you prior to arrival.  Together we can help to keep everyone safe.  Thank you for your co-operation 

If you have access to a thermometer, I would be grateful if you could take your temperature and note it here
By Checking the Boxes, you confirm that you agree with the following statements:
I understand that COVID-19 is highly contagious and still present in the community. I understand that it is passed through close contact with others and those without symptoms may be infectious leaving a risk of contracting the virus during treatment.
I agree to observe safety protocols advised by my therapist like hand sanitising
I consent to my contact details being held on record and shared, if asked, with HSE personnel for the explicit purpose of contact tracing in respect of COVID-19, as required by current government guidelines.
I agree not to visit the treatment room for any of the treatments provided if I have the symptoms of COVID-19. I acknowledge that the information I have given in this consent form is accurate and complete.