COVID-19 SCREENING AND CONSENT
This document is to be recorded by every customer who comes for a massage treatment, for True Thai Therapy, Edinburgh only. Please note that this information will not be shared with anyone, except the UK Government when needed for COVID-19 matters. However, you will be informed before your information is given to the government.
Appointment Date and Time *
Name - Surname *
Address *
Contact number *
Email address
TESTING
Have you had a Covid-19 test? If yes, when? Antigen or antibody test? Antigen – tests for Covid-19 on day of testing. Antibody – possible immunity *
If it was a positive result, has the isolation period expired?
Clear selection
Do you still have symptoms?
Clear selection
SYMPTOMS - Are you experiencing any of the following?
Severe breathing difficulties or chest pain, and difficulty in waking or confusion *
Fever, Onset, or worsening of a cough, Sore throat or runny nose, Chills or headache, Pain swallowing, Muscle & joint ache, Fatigue or exhaustion, Loss of taste or smell *
Shortness of breath or difficulty lying down due to chest issues *
Have you been in contact with anyone with Covid-19 symptoms? *
Have you recently been hospitalised? If so, why: *
Do you have any of the following health issues: High blood pressure or other heart condition, Diabetes Type 1 or 2, Cancer, Lung condition, Any other conditions – please list: *
Are you: An NHS front line worker, A carer – home or care home, Shielding a vulnerable adult, Pregnant – how many weeks?, Aged over 70, Allergic to latex gloves or specific cleaning products: Please state in the "other" box. *
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 Test & Trace I will inform you.

Full name & Date *
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