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 }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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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 }
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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 }
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Have you been told to stay home, self-isolate or self-quarantine? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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Have you tested positive or had treatment for COVID-19   {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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High Risk Clients (clinically extremely vulnerable) - Please tick if any of the following apply to you {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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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 }
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If client is under 18 years old to be signed by parent or guardian

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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 }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Booking Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Booking Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 firstError.message }
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 firstError.message }
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 firstError.message }
Have you been told to stay home, self-isolate or self-quarantine? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
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 firstError.message }
Have you tested positive or had treatment for COVID-19   {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
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 }
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If you have travlled outside of the UK, please state what country/ies you have travelled to, {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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{ 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 firstError.message }

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 firstError.message }

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

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}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Booking Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Booking Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ 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 firstError.message }
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 firstError.message }
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 firstError.message }
Have you been told to stay home, self-isolate or self-quarantine? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
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 firstError.message }
Have you tested positive or had treatment for COVID-19   {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
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 firstError.message }
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}
{ 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 firstError.message }

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 firstError.message }

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