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Covid-19 Screening For Clients

Prior to your appointment with Rejuvenate Me we ask you to fill in the form below.

This form & its contents are used to collect information about yourself and about your current health status.

The entire document will be kept for at least 21 days & will be used to screen clients who may be suffering from any respiratory illness.

By checking the boxes, you are agreeing to providing information that is correct & true. You may be refused treatment at any point before or during any procedure at the discretion of the practitioner.

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  • Purpose of this form: This form & its contents are used to collect information about yourself and about your current health status.

    The entire document will be kept for at least 21 days & will be used to screen clients who may be suffering from any respiratory illness.

    By checking the boxes, you are agreeing to providing information that is correct & true. You may be refused treatment at any point before or during any procedure at the discretion of the practitioner.

    Please tick the appropriate boxes in answer to the questions-

  • Do you have a new or worsening cough?
  • Have you had a temperature above 37 degrees in the past 14 days?
  • Do you feel feverish?
  • Do you have the chills / shakes?
  • Have you had any loss of smell or taste in the past 14 days?
  • Have you been in contact with anyone confirmed to have Covid-19 in the past 14 days? This includes yourself.
  • Have you been in a home or facility with anyone who has symptoms of a cough or a fever or chills in the past 14 days?
  • Have you travelled abroad yourself or live with anyone who has travelled abroad in the past 14 days?
  • If you have answered NO to all 8 questions, you may be allowed to proceed with a treatment. The final decision to treat remains with the practitioner.

    If YES to any questions, please call and cancel your appointment immediately. If NO to all, proceed to remaining statement.

    By signing the form below I am acknowledging the potential risk to contract the COVID-19 disease during services provided and have voluntarily agreed to accept services. You further agree and hereby release Rejuvenate Me & Medical Extras and their employees from any and all liability associated with your potential risk to contract NOVEL CORONAVIRUS (COVID-19).