Pre Treatment COVID-19 Form Please complete and return this form before your treatment. Do contact me if you have any questions. Thank you. Name(Required) First Last Email(Required) Phone(Required) Date of your treatment(Required) Symptoms(Required)Do you currently have COVID-19 or any symptoms of COVID-19? No Yes Please defer your treatment if you: are waiting for a COVID-19 test resulthave recently tested positive for COVID-19have a high temperature, new continuous cough, or a loss or change to your sense of smell or tasteIf you currently have symptoms of COVID-19 but have not yet had a test, please arrange one as soon as possible. If you have any other new or unusual symptoms, please discuss these with your therapist before your appointment.Have you had COVID-19(Required) No Yes If you received medical treatment for COVID-19, please seek verbal or written consent from your GP or consultant before treatment.Household or bubble symptoms(Required)Does anyone in your household or support bubble have COVID-19 or symptoms of COVID-19? If the answer is ‘yes’, please defer your appointment until it is safe to do so. No Yes External contact symptoms(Required)Have you been in close contact with anyone outside of your household/bubble in the past 10 days who has symptoms of COVID-19? If the answer is ‘yes’, defer having a treatment until it is safe to do so, unless you have been wearing medical grade PPE (e.g. you are NHS staff or a healthcare professional). No Yes Test and Trace(Required)Have you been contacted by the NHS Test and Trace service (or equivalent in your country) and told to self-isolate? If the answer is ‘yes’, please defer having treatment until it is safe to do so. No Yes Are you currently shielding?(Required)If yes, please defer treatments until you are no longer shielding. No Yes Are you classed as extremely vulnerable?(Required)If you meet the government’s definition of someone who is clinically extremely vulnerable, please discuss this further with me and seek verbal or written consent from your GP, midwife or consultant before having a treatment. If you are unsure if you are clinically extremely vulnerable, please refer to the NHS website at www.nhs.uk. No Yes On the day of your treatmentPlease check your temperature on the morning of your treatment. If it is higher than usual, or if you have any other symptoms, please contact your therapist to defer your treatment. Please ensure that you follow all procedures explained to you by your therapist, prior to treatment. Your therapist has carried out a full risk assessment and adheres to COVID-19 guidelines produced by the government and their professional association, the Federation of Holistic Therapists (FHT).For more information, visit fht.org.uk/coronavirus Please note that if your therapist develops symptoms of COVID-19 and tests positive for the virus, your contact details may be shared with NHS Test and Trace, or the equivalent service in your country (in line with GDPR/data protection), to help minimise the transmission of COVID-19 and support public health and safety.