Pre-Consultation Form (updated June2020)

Please complete and sign this pre-consultation form before your appointment at Soma Wellness, Ballydesmond.
 
On review of the form, I may contact you to ask you not to attend for your appointment at this time and we will discuss a suitable future appointment. 

Please answer all questions honestly.

Thanking you,
Anita O' Sullivan Wharton

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* 1. Your Name

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* 2. Please answer Yes or No.
In the last 14 days have you had any of the following symptoms: Cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms?
Please give details if you have.

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* 3. Have you been diagnosed with confirmed or suspected Covid19?

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* 4. Are you a close contact of a person who is a confirmed or suspected case of Covid19 in the past 14 days? (less than 2 meters for more than 15 minutes accumulative in 1 day)

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* 5. Have you been advised by a doctor to self isolate at this time?

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* 6. Have you been advised by a doctor to cocoon at this time?

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* 7. Do you consider yourself to be in the category of people at higher risk from coronavirus? 
If you are unsure whether or not you are in an at risk category, please visit the HSE website for more information.

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* 8. If your situation or answers to the above questions changes after you complete and submit this form you agree to inform Anita at Soma Wellness on 087-1917907 as soon as possible. 

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* 9. Please provide any other information you feel is relevant at this time

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* 10. I understand that Anita has taken every precaution to ensure her clients health and safety before, during and after appointments. 
I understand that my personal details will be held securely under GDPR and relevant information may be used for contact tracing process if necessary.
Please print you name and date to confirm your understanding of the above above.

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