TAANIA WOOD MICROPIGMENTATION BLACK PNG.

COVID-19 Pre-Screening Questionnaire

Please complete 48 hours** prior to your scheduled appointment. If you answer "yes" to any of the first four questions, please contact us immediately on 07484 118255

In signing this form, you confirm that you understand and agree with the information contained therein, and that you consent to attending Taania Wood Micropigmentation to have treatment.

**PLEASE NOTE - You must submit a completed form no more and no less than 48 hours prior to your scheduled appointment, ensuring also that you contact us immediately should you answer "yes" to any of the first four questions.

Failure to do so may result in your appointment being cancelled and your booking fee being forfeited. You will be required to pay a new booking fee before a new appointment is confirmed.

It is important that we have the most current status of your health in relation to COVID-19 as possible, and that any changes to your booking can be made without triggering our cancellation policy.

FIELDS MARKED * ARE MANDATORY

Client Full Name

Within the last 14 days, have you had a temperature at or above 37.8c or had a sense of fever, or experienced a new cough, new shortness of breath, new sore throat, or loss of taste or smell that you cannot attribute to another health condition?*

Yes

Within the last 14 days have you or a member of your household had a positive Lateral Flow or PCR test?

Yes

Within the last 14 days have you or a member of your household been isolating?

Yes

Within the last 14 days have you travelled outside the U.K?

Yes

Have you received the COVID-19 vaccination?

Yes

IMPORTANT: If the date of your last vaccination was within the last 14 days, or if you are due to have a vaccination within the next 14 days, please contact us immediately at taaniapca@gmail.com

I declare that the info I’ve provided is accurate & complete and I consent to my procedure. I also give consent that my details may be shared with the NHS for the purposes of Track & Trace. I have read Taania Wood Micropigmentation COVID 19 policy which has been sent to me (also available on www.taaniawood.com) which outlines the measures Taania Wood Micropigmentation has taken to minimise the risks to clients and I understand there are theoretical risks in attending my appointment. I understand that I am opting for an elective procedure for which I do not hold my technician liable should I contract COVID-19 and I would like to proceed with my desired treatment.

Initials & Date

Thanks for submitting!