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

    Testing Details
    Have you had a COVID-19 test?

    If you had a positive test result, has the isolation period expired?

    Do you still have symptoms?

    Symptoms: are you experiencing any of the following?
    Do you have a new or persistent cough?

    Do you have a fever (above 37.8 degrees)?

    Have you lost or experiencing a reduced sense of taste or smell?

    Have you been in contact with anyone with COVID-19 symptoms or been living in a household with someone who is self-isolating due to COVID-19 symptoms?

    If you answer YES to any of the above, you should self-isolate for 14 days and contact the NHS Test and Trace service.

    Current Health Issues: extra precautions with PPE may be required
    Have you recently been hospitalised?

    If so, why?
    High blood pressure or other heart condition?

    Diabetes Type 1 or 2?

    Cancer?

    Respiratory condition?

    Pregnant? How many weeks?

    Aged over 70?

    Previously contracted coronvirus (treatment may not be possible at this stage)
    Are you experiencing post COVID-19 circulatory complications (e.g. deep vein thrombosis, micro-embolisms, stroke symptoms or pulmonary embolism)?

    Exposure to COVID-19 (extra precautions with PPE may be required)
    Are you an NHS front line worker?

    Are you a carer working in a care home?

    Are you shielding a vulnerable adult?

    Allergies
    Are you allergic to latex gloves or any specific cleaning products?

    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 the information being found to be untrue and false, then I am aware I can be prosecuted for making a false declaration.

    If either I or someone I have been in contact with tests positive for Covid-19 or have been contacted by NHS Test & Trace I will inform you.

    Please prove you are human by selecting the House.

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