Covid Declaration Form

The form below MUST be completed no more than 24 hours before EACH session.

Please complete this in-depth Consultation form instead if you are a new client and have not been seen by Jayne before: Pre-Massage Consultation Form with GDPR and Covid Questions

Please complete this form instead if you have attended Jayne Sarah Therapies before but require therapy for a new condition, if you are pregnant, have recently had surgery, a change in medical information or have been prescribed new medication: Brief Consultation Form

Name
First Last
Covid 19 Declaration*
Please confirm the following statements. If you cannot agree to all of them, please detail below.
- I have not tested positive for COVID-19 in the last 7 days and I am not awaiting a test or a result of a test.
- I do not live with anyone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days.
- To my knowledge, I have not been in contact with anyone with symptoms of Covid-19, such as fever, a new persistent cough or loss of taste or smell, in the last 14 days.
- I have not been advised to self isolate as part of the COVID -19 contact tracing program or from any other source.
- If either I, or someone I have been in contact, with tests positive for Covid-19 or have been contacted by NHS Test and Trace I will inform you.
- I consent for Jayne Sarah Therapies to inform NHS Test & Trace if so required.
- I understand that by attending future sessions, I agree to all of the above on an ongoing basis and will cancel any future sessions should my health be compromised beforehand.
If you are unable to confirm any of the Covid statements above, please provide further information here:
AGREEMENT FOR THERAPY*
- I understand that I must give at least 24 hours notice to cancel sessions with Jayne Sarah Therapies, otherwise I will be charged a full price cancellation fee. (The only exception to this is a sudden onset of Covid symptoms)

Covid Declaration Form

Qualifications & Accreditations