Glo Client Covid-19 Consent Form

This form must be completed and submitted at least 5 days before the booking and in order for it to go ahead.

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Booking Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Booking Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Have you had a fever in the last 7 days? (feeling hot to touch on your chest and back) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Do you now, or have you recently had, a persistent dry cough? (coughing a lot for more than an hour or 3 or more coughing episodes in 24 hours or a worsening of a pre-existing cough) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has coronavirus-type symptoms? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Have you been told to stay home, self-isolate or self-quarantine? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Do you have any other symptoms that may mean you have a Covid-19 infection? (loss of taste and smell, unusual fatigue or shortness of breath) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Have you tested positive or had treatment for COVID-19 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Have you travelled outside of the UK in the last 21 days and if so where, and have you fulfilled the legal obligation to quarantine for 14 days? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

If you have travlled outside of the UK, please state what country/ies you have travelled to, {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

High Risk Clients (clinically extremely vulnerable) - Please tick if any of the following apply to you {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

If you have ticked any of these boxes after reading this list, you are classed as extremely vulnerable and the government advise that you exercise ‘shielding’.

Moderate Risk Clients - Please tick if any of the following apply to you: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

If you tick any boxes after reading this list, you are at moderate risk from coronavirus and it is very important you follow the advice on social distancing.

Consent for receiving a treatment/s with a practitioner from Glo Pamper Ltd.

I declare that the information I have provided is correct to the best of my knowledge and I understand that, because my treatment may involve touch and close physical proximity over a period of time, there may be an elevated risk of disease transmission, including Covid-19.

I consent to the Glo therapist retaining the details provided on this form for a period of 7 years from today. I further understand that if I am under 18 years of age*, these records will be kept until I reach the age of 25 (7 years after reaching 18).

I give my consent to receive treatment from the therapist assigned to my booking by Glo Pamper Ltd.

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

If client is under 18 years old to be signed by parent or guardian

Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Contact information herein will not be used for any other purpose other than specifically for this booking between Glo and your Glo Therapist.

Glo Client Covid-19 Consent Form

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Booking Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Booking Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you had a fever in the last 7 days? (feeling hot to touch on your chest and back) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you now, or have you recently had, a persistent dry cough? (coughing a lot for more than an hour or 3 or more coughing episodes in 24 hours or a worsening of a pre-existing cough) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has coronavirus-type symptoms? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you been told to stay home, self-isolate or self-quarantine? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have any other symptoms that may mean you have a Covid-19 infection? (loss of taste and smell, unusual fatigue or shortness of breath) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you tested positive or had treatment for COVID-19 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you travelled outside of the UK in the last 21 days and if so where, and have you fulfilled the legal obligation to quarantine for 14 days? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you have travlled outside of the UK, please state what country/ies you have travelled to, {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

High Risk Clients (clinically extremely vulnerable) - Please tick if any of the following apply to you {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you have ticked any of these boxes after reading this list, you are classed as extremely vulnerable and the government advise that you exercise ‘shielding’.

Moderate Risk Clients - Please tick if any of the following apply to you: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you tick any boxes after reading this list, you are at moderate risk from coronavirus and it is very important you follow the advice on social distancing.

Consent for receiving a treatment/s with a practitioner from Glo Pamper Ltd.

I declare that the information I have provided is correct to the best of my knowledge and I understand that, because my treatment may involve touch and close physical proximity over a period of time, there may be an elevated risk of disease transmission, including Covid-19.

I consent to the Glo therapist retaining the details provided on this form for a period of 7 years from today. I further understand that if I am under 18 years of age*, these records will be kept until I reach the age of 25 (7 years after reaching 18).

I give my consent to receive treatment from the therapist assigned to my booking by Glo Pamper Ltd.

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Contact information herein will not be used for any other purpose other than specifically for this booking between Glo and your Glo Therapist.

Glo Client Covid-19 Consent Form

This form must be completed and submitted at least 5 days before the booking and in order for it to go ahead.

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Booking Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Booking Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you had a fever in the last 7 days? (feeling hot to touch on your chest and back) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you now, or have you recently had, a persistent dry cough? (coughing a lot for more than an hour or 3 or more coughing episodes in 24 hours or a worsening of a pre-existing cough) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has coronavirus-type symptoms? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you been told to stay home, self-isolate or self-quarantine? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have any other symptoms that may mean you have a Covid-19 infection? (loss of taste and smell, unusual fatigue or shortness of breath) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you tested positive or had treatment for COVID-19 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you travelled outside of the UK in the last 21 days and if so where, and have you fulfilled the legal obligation to quarantine for 14 days? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you have travlled outside of the UK, please state what country/ies you have travelled to, {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

High Risk Clients (clinically extremely vulnerable) - Please tick if any of the following apply to you {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you have ticked any of these boxes after reading this list, you are classed as extremely vulnerable and the government advise that you exercise ‘shielding’.

Moderate Risk Clients - Please tick if any of the following apply to you: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you tick any boxes after reading this list, you are at moderate risk from coronavirus and it is very important you follow the advice on social distancing.

Consent for receiving a treatment/s with a practitioner from Glo Pamper Ltd.

I declare that the information I have provided is correct to the best of my knowledge and I understand that, because my treatment may involve touch and close physical proximity over a period of time, there may be an elevated risk of disease transmission, including Covid-19.

I consent to the Glo therapist retaining the details provided on this form for a period of 7 years from today. I further understand that if I am under 18 years of age*, these records will be kept until I reach the age of 25 (7 years after reaching 18).

I give my consent to receive treatment from the therapist assigned to my booking by Glo Pamper Ltd.

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Contact information herein will not be used for any other purpose other than specifically for this booking between Glo and your Glo Therapist.