Covid-19 Pre Treatment Questionnaire

Please note this questionnaire is a mandatory legal requirement in safe practice for the foreseeable future whilst COVID-19 is still a risk to us based on current UK government guidance.


Failure to cooperate & fill in these legal forms can result in refusal of treatment by ELM,


Please discuss with Emma any concerns, new or unusual symptoms. You can also use the NHS 111 online Coronavirus service for assistance.


HONESTY IS KEY FOR THE SAFETY OF EVERYONE. please respect the health of others and fill in this form with truthful representation of your current health.


Please scroll down to complete the questionnaire and for further information. 

Thank you for your co-operation.

Your form message has been successfully sent.

You have entered the following data:

COVID-19 Mandatory Pre Treatment Questions

Please correct your input in the following fields:
Error while sending the form. Please try again later.

Note: Fields marked with * are required

Please be aware that the contents of this form are not encrypted

NHS Link for COVID-19 High and Moderate Risk Health Conditions


If you are classed as a clinically extremely vulnerable person (high risk) and require sheilding, you will have received a letter from the NHS explaining this. It is highly recommended to defer treatment with ELM until the government indicates that it is safe for you.


If you are classed as a vulnerable person (moderate risk) you will not have received a letter from the NHS. If you are unsure if you are clinically vulnerable, please refer to the NHS website. If you meet the definition of someone who is clinically vulnerable, please discuss this further with your therapist and seek consent from your GP, midwife or consultant before having a treatment with us.

Book an Appointment

Need more information?

Already an Existing Client?

I thoroughly hope you 

enjoyed your treatment

with ELM and appreciate

your feedback.

Please feel free to

leave a comment

on our Testimonial page!

Follow ELM on socials by clicking on the icons below!

Print Print | Sitemap Recommend this page Recommend this page
Emma Leeson Massage (ELM) Copyright© 2012. All Rights Reserved.