Coronovirus health declaration

All clients receiving a service from Nicola Whitfield MUA must fill out this form 12-24 hours prior to their service.

In the event that the form is not received by Nicola Whitfield MUA I may have to decline to provide services to the client & any other persons for that booking.


Please note, for the purpose of this Questionnaire, contact with a person includes any of the following:


  • - Living in the same household regardless of whether you are social distancing or not.

  • - Face to face contact for any length of time regardless of whether PPE was worn or not.

  • - Being within 2m of another person outside your household for any length of time regardless of whether PPE was worn or not.

Coronavirus Covid - 19 Health Declaration

Have you or any member of your household experienced any of the following symptoms, in the past 14 days.  Including but not limited to;

muscle pain, diarrhoea and vomiting

loss of sense of smell and/or taste, extreme exhaustion

a new or persistent or dry cough, a temperature or shortness of breath


If yes, please provide the dates on which the symptoms were experienced and who experienced them in an email to

Please tick all boxes which apply below:

* The full Coronavirus Policy can be found here

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