Please complete the following COVID-19 screening and consent form before attending your 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

    Are you registered on a Test & Trace app?

    Testing and Vaccinations
    Have you had a COVID vaccination?

    If so, when?

    Have you had a positive COVID test in the past 14 days? (either lateral flow or NHS PCR)

    Have you been in contact with anyone with either COVID-19, or having COVID-19 symptoms, in the past 14 days?

    Has anyone in your household been in contact with anyone with either COVID-19, or COVID-19 symptoms, in the past 14 days?

    If you replied yes to any of the last three questions, you should self isolate according to government advice

    SYMPTOMS - Have you experienced any of the following in the last 7 days?
    Fever

    Persistent cough or having breathing difficulties

    Loss of taste or smell

    If you replied yes to any of the last three questions, then you should organise a COVID test and self isolate until the results are known

    Have you developed any additional medical conditions since the initial/previous consultation?

    Please provide the details of these conditions (e.g. pregnancy, surgery, long covid, hospitalisation)

    Have you?
    Arrived in the UK from abroad in the last 14 days?

    If so, from which country

    Travelled within the UK in the last 14 days?

    If so, where

    Are you?
    Allergic to latex gloves or any cleaning products

    A higher risk individual? (If so, please indicate which)

    Signed
    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.

    Should anyone I have been in direct contact with over the past 14 days tests positive for Covid-19 I will take advice from NHS Test & Trace, my GP, 111 and 119 as to whether it is necessary to inform you

    Please prove you are human by selecting the Tree.

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