covid 19 pre-appointment screening form

Please complete the following form and press the 'Submit' button within 48 hours of your appointment. If you aren't sure of how to answer any of the questions, please don't hesitate to get in touch. Many thanks.           

By submitting this form this is your declaration: I declare that the information I have provided is true and correct and I make this declaration conscientiously believing the same to be true. I consent to my information being shared with NHS Test & Trace service should it be required.

COVID 19 - Ongoing Screening Form
  • Are you registered on the NHS Test & Trace app?:
  • TESTING - Have you had a positive Covid-19 test in the past 14 days?:
  • TESTING - Are you waiting for the results of a Covid test?:
  • Have you been in contact with anyone with either Covid-19, or Covid-19 symptoms, in the past 14 days?:
  • Has anyone in your household been in contact with anyone with either Covid-19, or Covid-19 symptoms in the past 14 days?:
  • SYMPTOMS - Have you experienced any of the following in the last 7 days?:
    • High temperature or feeling feverish?:
    • Persistent cough or having breathing difficulties?:
    • Loss or change to sense of taste or smell?:
    • Cold-like symptoms such as headache, runny nose, sneezing or sore throat?:
    • VACCINATION - Have you had the Covid-19 Vaccination?:
    • If you have had the Covid-19 Vaccination/s was the vaccination more than 3 weeks ago?:
    • GENERAL HEALTH - Have you had any changes to your health (even minor changes) since your last massage appointment?:
    • COVID - Have you had Covid-19?:
    • TRAVEL - Have you arrived in the UK from abroad in the last 14 days?:
    Calico Pregnancy Massage Covid 19 Form