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COVID-19 SCREENING FORM

Covid-19 Screening Form

Please complete this form within 48 hours of your massage treatment, thank you.

First Name

Last Name

Email

I confirm that I have not had any of the following symptoms in the last 14 days: fever, dry, persistent cough or a loss of sense of taste or smell.

I confirm that I am not in the clinically extremely vulnerable category and therefore advised to shield at home by the government.

I haven’t been in close contact with a Covid-19 patient in the last 14 days

Initials

Date

I declare that the info I’ve provided is accurate & complete.

Thanks for submitting!

NRG Therapy - RISK-ASSESSMENT- Covid-19.