Safety First

The health and well being of our community is our first priority. We have taken several measures to protect our clients and community. Please fill out the form below and bring to your appointment. Your temperature will be measured on arrival.

Coronavirus Self-Declaration Form                                                   Date:

 

Due to the ongoing and rapidly changing situation with the novel-coronavirus (COVID-19), we are requiring all visitors to Asenta Aesthetics Ltd to fill-out the self-declaration form below. 

Each visitor must complete this form.

 

Full Name: 

Date of Birth: 

Temperature:

 

  1. Do you have or have had (past 2 weeks) any of the following flu-like symptoms:

 

    Fever (38° or higher)           ⬜ Yes ⬜ No 

    Cough                                    ⬜ Yes ⬜ No

    Breathlessness                    ⬜ Yes ⬜ No 

    Sore throat                           ⬜ Yes ⬜ No 

    Changes in taste or smell   ⬜ Yes ⬜ No 

    Other Please Specify:

 

    2.Please list the country/cities you have travelled to in the last 14 day.


 

   3. Have you or an immediate family member come in close contact with a confirmed case of the coronavirus in the last 14 days?       (“Close contact” means being at a distance of less than one metre for more than 15 minutes.) ⬜ Yes ⬜ No 

 

This document will be retained confidentially by Asenta Aesthetics Ltd. 

The health and wellbeing of our community is our first priority therefore I give consent to Asenta Aesthetics Ltd to share my details with Covid-19 track and trace if required.

I have read and answered all of the above statements.

 

Signature:       _______________________________________________

 

Print Name:    _______________________________________________

© 2017, 2018 by Asenta Aesthetics.

Clinic operated by Asenta Aesthetics Ltd. Winford Manor. Bristol BS40 8DW. poppy@asenta.co.uk

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