Corona Virus Screening

Please could you complete the following form for prior to your treatment.

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

We are structuring sessions for you to have the best (and safest) experience under the "new normal". You will need to complete a Corona Virus Screening form before your first session. Virtual sessions are still available.

Stay safe and sane. Hope to see you soon. With warm regards, Regina

Current Covid-19 symptoms

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*

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