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 on 0794 227 6538, or via our landline 0115 648 9636, or the contact form.

Sessions are available 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.

This Form cannot be submitted until the missing
fields (labelled below in red) have been filled in

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)