Corona Virus Screening

Please could you complete the following initital Coronavirus screening form before your treatment. This will save time during our session.

New clients will need to complete the Corona Virus Screening form.

We are structuring sessions for you to have the best and safest experience in the current situation. I will continue to wear a face covering, and kindly request clients to wear a face covering, too (unless exempt).
I am fully vaccinated.

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, or if you have a positive Covid test.

Covid-19 screening and risk factors

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

I have *

	not been vaccinated againd Covid-19
	had my first dose
	had both doses of the Covid-19 vaccine
	had a booster

Have you had Covid-19?
If yes, please describe: when, whether tested, severity, post-viral effects.

Are you at high(er) risk of getting Covid-19?
this can be, amongst others,
due to age, pregnancy, immunosuppression or diabetes.

Your reason for treatment: *

Is there anything else we should know?

Full name*

Postal address including postcode*

E-mail address*

Contact telephone number*

Occupation

Date of birth*

	understand that the treatment is no substitute for medical advice
	will let the practitioner know immediately if I feel uncomfortable at any time during the session
	understand that if I cancel a session less than 48 hours prior to the start of the session I am liable for the full fee, unless negotiated otherwise and/or is related to Covid.

By sending this form you*

	consent to having treatment
	are aware of the risks
	currently do not test positive for Covid-19
	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)