Please complete the following Client COVID-19 declaration form before attending your follow up session with Deep Impact Massage, alternatively you can download a paper copy here.

All information you enter here is securely transmitted and encrypted.

    Contact Details:
    Your full name

    Your full address

    Your date of birth

    Your email

    Your contact mobile

    Your COVID Declarations
    I AM registered with NHS Test and Trace App

    I HAVE had a COVID-19 vaccination

    First injection date (leave blank if not received)

    Second injection date (leave blank if not received)

    I have NOT had a positive NHS or LFD lateral flow COVID-19 test in the past 14 days

    To my knowledge, I have NOT been in contact with anyone with either COVID-19 or COVID-19 symptoms in the past 14 days

    I am NOT experiencing any COVID-19 symptoms

    I have NOT travelled out of the UK in the past 14 days

    Should anyone I have been in direct contact with over the past 14 days tests positive for COVID-19 I WILL inform you immediately

    Signing your declaration
    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.

    If any person should suffer as a result of this information being found to be untrue and false, then I am aware I can be prosecuted for making a false declaration.

    Please prove you are human by selecting the Star.

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