Corona Virus Screening

Please complete the form below before you come for your treatment.

I will need to keep the information you send in line with General Data Protection Regulation (“GDPR”).

You can reach Touching Well by mobile: 0794 227 6538, or via our landline 0115 648 9636, or the contact form.

Opening times: Monday to Thursday daytime

I hope to see you soon. With warm regards, Regina

These are the most common Covid-19 symptoms.

Loss or change to your sense of smell or taste – this means you have noticed you cannot smell or taste anything, or things smell or taste different to normal.
High temperature – this means you feel hot to touch on your chest or back.
New, continuous cough – this means coughing for a lot more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual).

Please cancel if you have Covid-19 symptoms.

Please note that all fields followed by an asterisk must be filled in.

First Name*

Last Name*

Date of birth*

E-Mail Address*

Contact number*

Have you had your Covid vaccine*

If you have been vaccinated, please say when

By sending this form you *

	consent to having treatment
	are aware of the risks
	currently do not test positive for Covid-19
	currently do not have corona virus symptoms (or any other potentially contagious condition)
	will cancel treatment if you have Covid-19
	will inform Touching Well should you develop Covid-19 within a week of treatment
	will wear a face covering (unless exempt)