COVID Information & Consent Form

Name *

First

Last

Email *

Date completing form *

Enter as DD-MM-YYYY

Date of first session *

Enter as DD-MM-YYYY

Have you had a fever in the last 24 hours of 38°C or above? *

Yes
No

Do you now, or have you recently* had, any respiratory or flu symptoms (including fever, chills, sore throat, cough, muscle aches, or shortness of breath)? *

Yes
No

*’recently’ implies within the last 10-14 days.

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? *

Yes
No

Have you traveled anywhere outside of the UK in the last two weeks? *

Yes
No

If yes, please state the location(s) you travelled to:

Have you had a new loss of sense of taste or smell? *

Yes
No

Can you exercise to get your heart rate and respiratory rate up without any problem? *

Yes
No

Have you recently* had a new onset of muscle aches and pain not attributable to exercise or injury? *

Yes
No

*’recently’ implies within the last 10-14 days

Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin? *

Yes
No

I agree to notify you if I develop symptoms or am given a diagnosis of COVID-19 within 10 days after my session… *

Yes
No

Consent for treatment *

I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organisation (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.
I understand that I am the decision maker with regards to my health. To the best of their ability, my practitioner will provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended interactions, and the benefits and risks associated with the provision of massage and bodywork during a pandemic. Given the current limitations of COVID-19 virus testing, I understand that accurately determining who is infected with COVID-19 is exceptionally difficult.
I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to my practitioner (Elizabeth Sheppard) to proceed with providing this bodywork session.
I understand that a copy of this consent form will be sent to me via email.

To proceed with receiving this touch and bodywork session, you confirm and understand the above points

Before submitting this form… *

I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING MASSAGE AND BODYWORK DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION. I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREATMENT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SUBMITTING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THIS SESSION FROM ELIZABETH SHEPPARD ON THE SESSION DATE REFERENCED ABOVE AND FOR ANY FUTURE SESSIONS.