Client Health Questionnaire Name* First Last Date of Birth* Date Format: DD slash MM slash YYYY Address* Street Address Address Line 2 City / Town Post Code Email* Enter Email Confirm Email Your Phone Number*Emergency Contact Name* First Last Emergency Phone Number*Health Questions Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.Have you been diagnosed with or been in contact with someone diagnosed/tested positive with COVID-19 in the past two weeks?*YesNoHave you developed symptoms of COVID-19 or been in close contact with anyone exhibiting these symptoms in the past two weeks?*YesNoHave you recently suffered from a new continuous cough, fever, chills, aches, shortness of breath or loss of taste or smell or generally felt unwell in the past two weeks?*YesNoDo you suffer from any of the following health issues (please ensure to tick 'No Medical History' if none of the following apply)* Diabetes Epilepsy Rheumatism Asthma Allergies Pregnancy Heart condition No Medical History Other Please provide details on any ticked boxes: I have read, understood and completed this questionnaire. I have not withheld any known medical history or condition. Initials* Liability waiver I agree to follow all COVID-19 hygiene recommendations by Fong Spa to keep others and myself safe. I hereby give my written consent for Fong Spa to carry out the treatments of my choice as requested by me. Initials* Cancellation policy Cancellations hurt our business so please provide a minimum of 24 hours notice if you need to amend/cancel your treatment appointment. I accept should the aforementioned required appointment cancellation notice not be provided, a 100% cancellation charge will apply to all appointments and refunds will not be issued.Initials*Date* Date Format: DD slash MM slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
