Covid-19 pre-treatment declaration form

Please complete the form below at least 24 hours prior to your treatment. If you have any of the Covid-19 symptoms, please seek medical advice.

On arriving for your appointment, you will have your temperature taken by a contactless device and you will be asked to sanitise your hands.

The treatment room is fully deep cleaned between each customer, and it is also cleaned each night by an ultraviolet light system, so you can be assured that you are coming to a safe and clean environment.

*information required

Full Name*

Telephone*

Email*

Do you have any of the following symptoms*: I have no symptoms
Fever/High Temperature (feeling unusually hot to the touch)
New, continuous cough
Loss or change to your sense of smell or taste

If you do have any of these symptoms, please seek medical advice and self-isolate. I will not be able to see you until you have a negative Covid-19 test result or 14 days have passed.

Have you received hospital treatment for Covid-19*? No
Yes

Are you currently taking medication for Covid-19*? No
Yes

If you have answered yes, treatment can only proceed with GP written approval.

Have you or any of your household been contacted by the Track and Trace Team and advised to self-isolate in the last 2 weeks*? No
Yes

Have you been in contact with a confirmed case of Covid-19 in the last 2 weeks*? No
Yes

If yes to any of the above treatment cannot take place until a negative test result has been received.

If yes to either of the above, have you taken a Covid-19 test since and you confirm it was negative? No
Yes

I agree that I am providing accurate health information*

By ticking the box 'I agree', you are stating to have answered the questions honestly and to the best of your knowledge for the safety of yourself and others.

Location / Contact

5 Robert Street, Williton, Taunton, Somerset. TA4 4PG

07794 993 495

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