top of page

COVID-19 Form

Name*

Email Address*

Booking Name

Booking date

Have you had a fever in the last 7 days

Select an option

Do you know or have you recently had a persistent cough or a worsening pre existing cough

Select an option

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

Select an option

Have you been told to stay home, self isolate or self quarantine

Select an option

Do you have any other symptoms that may mean you could have covid-19 infection such as loss of taste and smell, unusual fatigue or shortness of breathe

Select an option

Have you tested positive or had treatment for covid-19

Select an option

Have you travelled outside the UK in the last 21 days and if so where did you travel and have you fulfilled the legal obligation to quarantine for 14 days*

Select an option

If you have travelled outside the UK please state where you visited *

I agree I understand the high risk category for contracting covid-19 and I confirm I have no health conditions which put me in this category *

Select an option

I agree I understand the moderate at risk category for contracting covid-19 and if I fall in this category I understand I need to adhere to social distancing where possible *

Select an option

Name *

Signature *

Today's Date *

Consent for receiving treatments with a therapist from myblissfulretreat


I declare that the information I have provided is correct to the best of my knowledge and I understand that because my treatment may involve touch and close physical proximity over a period of time, there may be an elevated risk of disease transmission including covid-19.


I consent to the myblissfulretreat team and therapist retaining the details provided on this form for a period of 7 years from today.  I further understand if I am under 18 years of age these records will be kept until I reach the age of 25 (7 years after reaching 18)

I give consent to receive treatments from the therapist assigned to my booking by myblissfulretreat 


Please sign and date at the bottom of the form and submit your answers 48 hours before your booking in prder for your booking to go ahead.

bottom of page