BLOOM
About You
Appointment Details
Health Assessment
Have you or any members of your household or social bubble experienced any of the following symptoms in the last 14 days? If yes we ask that you reschedule your appointment.
In the past 14 days have you / any members of your household / any member of your social bubble knowingly had any contact with a confirmed case of Covid-19 and / or are in the self-isolation?
If yes I ask that you reschedule your appointment.
In the past 14 days have you travelled abroad / outside of the UK?
If yes, I ask that you reschedule your appointment.
Would you consider yourself high risk, 'shielding', or have any other medical conditions that could increase your vulnerability to Covid-19?
Declaration
By continuing with an appointment I fully understand and acknowledge that although Bloom with Beth has taken reasonable steps to minimise the risk, they are unable to 100% remove the risk of infection of
Covid-19 (Coronavirus) along with other illness' or infections.
I have filled in the above information accurately, and I will contact Bloom with Beth if anything changes.
I understand that if I am vulnerable, 'shielding' or have any underlying medical conditions, I continue with the appointment at my own risk.
I agree to read Bloom with Beth's Covid-19 Policy once I have submitted my form.
Your Signature