Your details * denotes mandatory questions Your Name* Your Email* Phone* Have you displayed any of the following symptoms? YesNo Have you felt hot to the touch on your chest or back in the last 7 days?* YesNo Have you coughed a lot, for more than an hour or had 3 or more coughing episodes in the last 24 hours?* YesNo Have you noticed any changes in your senses of smell or taste?* If you have answered "Yes" to any of the above, please obtain a coronavirus test and stay at home until you get your result. Risk factors Consider high-risk factors such as, but not limited to, receiving cancer or organ transplant treatments, taking immunosuppressant medication or large doses of steroids, living with a severe lung condition. YesNo Do you consider yourself at high risk of corona virus?* If you consider yourself ‘high risk’ please consider shielding and don’t book a massage at this time. Consider moderate factors such as, but not limited to, your age, are you over 70 years old? Are you diabetic, asthmatic or taking low doses of steroids? YesNo Do you consider yourself at a moderate risk of corona virus?* If you consider yourself at a moderate risk of corona virus please think carefully before booking and contact me by telephone if you would like to discuss further Declaration: I understand that my treatment will involve touch and close physical proximity, breaking social distancing guideline for more than 15 minutes. I understand there may be an elevated risk of disease transmission including Covid-19 as a result. I understand that my contact details may have to be shared for track and trace purposes. I give my consent to receive treatment.