Covid screening and consent form

Before your first treatment, please submit this Covid screening and consent form.

Full Name

Email Address

Phone Number

Date of birth

Covid-19 Screening Information. Tick the box to answer "Yes" to the question. If you answer "Yes" to any of the questions, please contact us immediately.

Have you had a fever in the last 10 days? (Feeling hot to touch on your chest or back)

Do you now, or have you recently had a presistent cough? (Coughing a lot for more than an hour, 3 or more coughing episodes in 24 hours or worsening symptoms of a pre-existing cough)

Have you lost sensation of taste or smell?

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

Have you been asked to stay at home, self-isolate or self-quarantine?

Clinically Vulnerable

If you or anyone you live with falls into the 'clinically vulnerable' or 'clinically extremely vulnerable' categories, and we have not already discussed this, please contact us immediately.

I understand that, because my treatment may involve touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including Covid-19. In the eventuality that the practitioner gets symptoms of Covid-19 within 48 hours of having close contact with me during an appointment and then they later test positive, the practitioner is obligated under law to provide my name, phone number or email and the date and time of my visit to the test and trace service.

I declare that the information I have provided on medical history is correct to the best of my knowledge and hereby give consent for acupuncture to be carried out by Acupuncture by Ella Nazar Limited. I confirm that I have been provided with written information on the potential complications associated with the procedure, aftercare advice and the privacy notice location, all contained in the “Information Sheet” on the “Clinic Info” page of the website.

Type your full name here to sign the consent

Today's Date

Thank you for submitting!