(please complete no more than 24 hours before your appointment or attendance to any workshop or training session)
Your Name (required)
Your Email (required)
Your Therapists Name
Session Appointment Date (required)
WITHIN THE LAST 14 DAYS, HAVE YOU EXPERIENCED A NEW COUGH THAT YOU CANNOT ATTRIBUTE TO ANOTHER HEALTH CONDITION? (required) YesNo
WITHIN THE LAST 14 DAYS, HAVE YOU EXPERIENCED NEW SHORTNESS OF BREATH THAT YOU CANNOT ATTRIBUTE TO ANOTHER HEALTH CONDITION? (required) YesNo
WITHIN THE LAST 14 DAYS, HAVE YOU EXPERIENCED A NEW SORE THROAT, LOSS OF TASTE OR SMELL THAT YOU CANNOT ATTRIBUTE TO ANOTHER HEALTH CONDITION? (required) YesNo
WITHIN THE LAST 14 DAYS, HAVE YOU HAD A TEMPERATURE AT OR ABOVE 37.8°C OR THE SENSE OF HAVING A FEVER? (required) YesNo
WITHIN THE LAST 14 DAYS, HAVE YOU HAD CLOSE CONTACT WITH SOMEONE WHO IS OR WAS SICK WITH SUSPECTED OR CONFIRMED COVID-19? (NOTE: CLOSE CONTACT IS DEFINED AS WITHIN 6 FEET FOR MORE THAN 10 CONSECUTIVE MINUTES) (required) YesNo
WITHIN THE LAST 14 DAYS, HAVE YOU OR A HOUSEHOLD MEMBER BEEN ISOLATING? (required) YesNo
**If you answer yes to any of these questions, please reschedule your appointment
I HAVE READ THE COVID19 PROCEDURES STATEMENT ON THE TANTRIC JOURNEY WEBSITE WHICH OUTLINES THE MEASURES TANTRIC JOURNEY HAVE TAKEN TO MINIMISE RISKS TO CLIENTS AND STUDENTS; AND UNDERSTAND THERE ARE THEORETICAL RISKS IN ATTENDING MY APPOINTMENT AND AGREED TO ATTEND THE SESSION. I have read and agreeI do not agree
YOUR SIGNATURE (required)
