Covid Secure Form
Adomas Miklys Massage and Personal Training
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Date of treatment*
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COVID pre-treatment questions
Do you currently have COVID-19, or any symptoms of COVID-19?
Yes No
Please defer your treatment if you:
- are waiting for a COVID-19 test result.
- have recently tested positive for COVID-19.
- or have a high temperature, new continuous cough, or a loss or change to your sense of smell or taste.
If you currently have symptoms of COVID-19 but have not yet used the NHS 111 online coronavirus service, please do so. If you have any other new or unusual symptoms, please discuss this with your therapist before your appointment.
Have you had Covid-19?
Yes No
If you have had COVID-19, please seek verbal or written consent from your GP or consultant before treatment.
Does anyone in your household or support bubble have COVID-19, or symptoms of COVID-19?
Yes No
Have you been in close contact with anyone else in the past 14 days who has symptoms of COVID-19, or been contacted by the NHS Test and Trace service and told to self-isolate?
Yes No
If yes to either question, please defer seeing your therapist until it is safe to do so.
Are you currently shielding?
Yes No
If yes, please defer treatments until you are no longer shielding.
Are you classed as clinically extremely vulnerable or clinically vulnerable?
Yes No
If you meet the Government's definition of someone who is clinically extremely vulnerable (high risk) or clinically vulnerable (moderate risk), please discuss this further with your therapist and seek verbal or written consent from your GP, midwife or consultant before having a treatment (If you are unsure if you are clinically extremely vulnerable or clinically vulnerable, please refer to the NHS website at www.nhs.uk).
Your therapist has carried out a full risk assessment and adheres to COVID-19 guidelines produces by the government and her professional association (Complementary Therapists Association).
Please note that if your therapist develops symptoms of COVID-19 and tests positive for the virus, your details may be shared with NHS Test and Trace (in line with the GDPR/data protection), to help minimise the transmission of COVID-19 and support public health and safety.
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Covid Secure Form

COVID pre-treatment questions