Have you had a Covid Vaccination? If so which one?
Do you have any of the following symptoms
Have you been classified as belonging to any of the following vulnerable categories?
IF YES TO ANY - We will be in touch with you to discuss your treatment options
Checks on the door
• I acknowledge the contagious nature of the Coronavirus/Covid-19 and that the WHO and many other Public Health authorities still recommend practicing social distancing.
• I further acknowledge that Firm and Tender Hands has put in place preventative measures to reduce the spread of the Coronavirus/Covid-19.
• I further acknowledge that Firm and Tender Hands cannot guarantee that I will not become infected with the Coronavirus/Covid-19.
• I understand that the risk of becoming exposed to and/or infected by the Coronavirus/Covid-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, clinic staff, and other clinic patients and their families.
• I voluntarily seek services provided by Firm and Tender Hands and acknowledge that I am increasing my risk to exposure to the Coronavirus/Covid-19.
• I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
In consideration of my participation in the foregoing, the undersigned acknowledge and attest that:
• I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
• I have not travelled internationally within the last 14 days.
• I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/Covid-19.
• I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by local public health authorities.
• I am following all WHO recommended guidelines as much as possible and limiting my exposure to the Coronavirus/Covid-19.
• I will bring my own towels to keep warm during the massage in order to reduce risk of COVID-19 transmission.
• I will submit to a temperature check at the door of the therapy room on arrival.
• I solemnly and sincerely declare that the information I have provided is true and correct and I make this solemn declaration conscientiously believing the same to be true, further to this if any of the answers to these above questions change between the time of filling in this form, and the time of my appointment, I will inform the practitioner. If any person should suffer as a result of the information being found to be untrue and false, then I am aware I can be prosecuted for making a false declaration.