Coronavirus safety consultation

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Thank you for providing this information which will help keep both of us safe and makes massage therapy possible.

  • You will need to complete and send this form on the day of your treatment.

Address
Questions Yes No
If any of the above, the advice is to self-isolate for 7 days
If any of the above, the advice is to self-isolate for 7 days, and then taking a test will be necessary. Call 119
If any of the above, contact your GP or call 111
Digital signature

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Check the box above to digitally sign this declaration.

Declaration
I have read the terms and conditions below.


The information I have provided is true and correct to the best of my knowledge and I make this declaration in good faith.

If any of this information changes prior to an appointment I will inform you before the apppointment.

If I, or someone I have been in contact with, has symptoms of Covid-19, or tests positive for Covid-19,  or has been contacted by NHS Track & Trace I will inform you before my appointment. 

I understand I can be prosecuted for making a false declaration if any person should suffer as a result of the information being found to be untrue.


I consent for you to inform NHS Track & Trace if so required.    

  • I understand that the massage I receive is provided for the basis purpose of relaxation and relief of muscular tension.
  • If I experience any pain during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.
  • I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or qualified medical specialist for any mental or physical ailment of which I am aware.
  • I understand the massage therapists are not qualified to diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.
  • I understand that massage should not be performed under certain medical conditions, and I have stated all my known medical conditions above.
  • I will let the therapist know before future treatments if my medical condition changes and understand that it is my responsibility to do so.
  • I acknowledge that should I be late for my appointment the therapist has the right to alter the length of my massage to suit the needs of the office schedule.
  • I also understand that any inappropriate or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.