Please take the time to complete this form before you attend your appointment. 

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Your health, safety and well-being is my priority, and I kindly ask you complete this compulsory form.

Please complete at least 24 hours before your appointment.

If you do not complete this form, your appointment will be cancelled.

Please inform Bloom with Beth using the links above if any of the information below changes before your appointment.

By completing this form you consent to Bloom with Beth holding personal and sensitive data in accordance with GDPR.

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.