Maga Therapy | Specific Covid-19 Screening Info

At Maga Therapy we value health. As a result of COVID-19, there are some legally required changes.

This post discusses one of the forms which you will be required to bring on the day of your treatment – Covid-19 screening information. You will be sent this when you book your massage or other permissible treatment.

Before you enter the building I will scan (and record) your temperature. Please know that for your assurance, I will also scan and record my temperature. If the reading is above 37.8 you will not be allowed to enter the building.

There are other requirements in align with the new regulations. Please

 

FULL NAME  
FULL ADDRESS  
POST CODE  
EMAIL ADDRESS  
MOBILE NUMBER  
 
TESTING
Have you had a Covid-19 test YES NO
Did you self-isolate YES NO
What was the date you tested negative
Do you still have symptoms YES NO
Are you registered on the NHS Track & Trace app YES NO
SYMPTOMSAre you experiencing any of the following?
Severe breathing difficulties or chest pain YES NO
Difficulty in waking or confusion YES NO
If yes to any of the above call 999
Fever YES NO
Previous symptoms getting worse: cough YES NO
Sore throat or runny nose YES NO
If any of the above, the advice is to self-isolate for 7 days
Chills or headache YES NO
Painful swallowing YES NO
Muscle & joint ache YES NO
Fatigue or exhaustion YES NO
Loss of taste or smell YES NO
If any of the above, the advice is to self-isolate for 7 days. Then taking a test will be necessary. Call 119.
Shortness of breath or difficulty lying down due to chest issues YES NO
If any of the above, contact your GP or call 111
Have you been in contact with anyone with Covid-19 symptoms? YES NO
Have you had or are you now experiencing Covid-19 symptoms? YES NO
Are you taking your temperature regularly? If so, what is the latest? YES NO
Have you recently been hospitalised? YES NO
If so, why – please describe:
Do you have any of the following health issues
High blood pressure or other heart condition YES NO
Diabetes Type 1 or 2 – if so, which? YES NO
Cancer YES NO
Lung condition YES NO
Any other conditions – please list:
Are you?
An NHS front line worker YES NO
A carer – home or care home YES NO
Shielding a vulnerable adult YES NO
Pregnant – how many weeks? YES NO
Over 70 – will you have a companion with you? YES NO
Allergic to latex gloves YES NO
Allergic to cleaning products – if yes please specify YES NO
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 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 Track & Trace I will inform you.

 

I consent for you to inform NHS Track & Trace if so required.

 

Full name: ………………………………………………

Date:          ………………………………

 

 

 

 

THERAPIST DECLARATION & CONSENT FORM – COPY FOR CLIENT

 

FULL NAME

 

FULL ADDRESS

 

POST CODE

 

EMAIL ADDRESS

 

MOBILE NUMBER

 

 

 

I do not have Covid-19 to my knowledge

 

I have/ have not been tested for Covid-19

 

The test was negative

 

I take my temperature every day

 

I have not been in contact with anyone with Covid-19, to my knowledge

 

I am connected to the NHS Track & Trace app

 

If either I, or a client, tests positive for Covid-19 I will inform you immediately

 

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

 

Full name: ………………………………………….

 

Date:            ……………………………….

 

 

 

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