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Client Health Consultation and Covid Screening Form

This form must be completed and submitted at least 5 days before the booking.

Have you had any operations, illness, injuries over the last 12 months?
Do you suffer from any allergies?
Are you currently taking any prescribed medicine?
Are you currently receiving treatment from a GP/health professional?
Do you currently have any of the following conditions:

Covid 19 Screening 

Have you had a fever in the last 7 days? (feeling hot to touch on your chest and back)
Do you now, or have you recently had, a persistent dry cough? (coughing a lot for more than an hour or 3 or more coughing episodes in 24 hours or a worsening of a pre-existing cough)
Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has coronavirus-type symptoms?
Have you been told to stay home, self-isolate or self-quarantine?
Do you have any other symptoms that may mean you have a Covid-19 infection? (loss of taste and smell, unusual fatigue or shortness of breath)
Have you tested positive or had treatment for COVID-19
Have you travelled outside of the UK in the last 21 days and if so where, and have you fulfilled the legal obligation to quarantine for 14 days?

Consent for receiving a treatment/s with a practitioner from Love Pamper Company. 

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By completing this form, I confirm that I am the person named in this form, and have completed the form as fully and accurately as I can. I believe the details to be correct and consent to having treatment with the love pamper company practitioner assigned to my booking.

I release the practitioner from any negligent misrepresentation that may be contained in this form. I give permission for Love pamper company to share this information with the therapist allocated to my booking only and understand that otherwise this information will be treated confidentially and not shared with anyone else.

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I declare that the information I have provided is correct to the best of my knowledge and I understand that, because my treatment may involve touch and close physical proximity over a period of time, there may be an elevated risk of disease transmission, including Covid-19.

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I give my consent to receive treatment from the therapist assigned to my booking by Love Pamper Company.

Thanks for submitting!