Screening Form

Due to the global COVID-19 pandemic, it is essential that this form is submitted prior to arranging a booking at the clinic.

Full Name *

Email Address *

Phone Number

Please tick to confirm the following statements are true to you:I am not suspected to have had or suffered from COVID-19 virus in the last 21 days.I have not come into contact or are living with someone who is suspected or confirmed of having COVID-19 in the last 21 days.I am not displaying symptoms of COVID-19 such as a high temperature (a temperature greater than 37.8c), a new & continuous cough, or a loss or change to your sense of smell or taste. I am not pregnant.I am not over 70 years of age.I am aware that I must keep accessories to a minimum i.e. no; jewellery, handbags, shopping bags or luggage that are not required for your visit to the clinic (reducing the risk of cross contamination).I must bring my own pen to my appointment.If I am having a facial treatment, skin should be clean and free of make-up prior to attending my appointment.If I am having a body treatment, I must be prepared with warm clothing for areas not being treated as windows will be open to allow for ventilation. I must attend my appointment unaccompanied.I must attend my appointment on time and wait at the designated signpost area outside of the clinic until called (the sign post will read "Wait Here For Your Appointment").I understand I must follow social distancing measures at all times during my visit to the clinic (except during treatment).I understand that toilet facilities and reception waiting areas are not accessible on my visit to the clinic.I must use hand sanitiser upon entering the clinic and this is available after entering the first door at ground floor level.I understand that I must not attend the clinic if any of my health circumstances/risks change prior to me attending my appointment and I must inform the clinic immediately.I give consent for my details to be revealed to the NHS for Track and Trace if asked.

If there is a/any box not ticked above, please give details why:0 / 50

Relevant health conditions that you feel we should be aware of (please list any):i.e. Do you suffer from any of the following? Diabetes, cardiovascular disease, including hypertension, any respiratory disorders chronic lung disease, immunodeficiency, cancer under active treatment?0 / 180

SCORE 14/14

Submit Form - Confirm