Covid Track & Trace | essenceofcalm

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ESSENCE OF CALM

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Covid-19 Health Declaration

How are you feeling today?

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Full Name

Phone

I have not travelled outside of England in the last month

I am not experiencing the symptoms: fever (body temp over 37.5C), cough, sore throat, loss of taste or smell

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

I understand that this business and health practitioner cannot be held liable should I experience exposure to the virus or any other contagion as a result of my providing misinformation on this form.

Today your therapy is with:

By submitting this form, I acknowledge that I am aware of the risks involved and give consent to receive therapies with Essence of Calm

The information supplied in this form may be used for the purposes of NHS Track & Trace.

312 North Road, Darlington, DL1 2EW (United Kingdom)

07498 930406

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