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Ayurvedic Consultation

Mental Health Counselling

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Reiki & Energy Healing

Ayurvedic Massage

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Ayurvedic Facials

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Corporate

Programs, Classes & Speaking Events

Take-Home Meals

Blog

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COVID-19 Data Collection Form

ANANDA WELLNESS

COVID-19 Statement & Data Collection Form

Rear 137, Station St. Fairfield. VIC 3078. Tel: (04) 21674093; ABN: 65972507258

Following the COVID-19 pandemic, we’ve put extra measures in place for the safety of you and our staff members. We require all clients to fill in our COVID-19 Form before arrival so that we can provide the best possible and safe experience to our clients and staff members.

Please carefully read and answer the below questions. This information will be stored confidentially and securely for a minimum of 56 days.

If you or a member of your household has developed a cough, fever, breathlessness, sore throat or headaches in the last 14 days, please contact us before your appointment so we can obtain further information from you and advise. Please get in touch if you have any questions - we’re looking forward to welcoming you back.

Name *

First Name

Last Name

Phone *

(###)

###

####

Email *

Suburb, State *

Checkbox *

Do you answer YES to any of the following? IF NONE, PLEASE SELECT 'NONE OF THE ABOVE' FROM THE LIST.

Do you, or anyone in your household, have any flu-like symptoms?

Are you experiencing chills or sweats?

Are you experiencing a cough?

Are you experiencing a shortness of breath?

Are you experiencing a sore throat?

Are you experiencing a Runny nose?

Are you experiencing a loss of sense of smell?

In the last 14 days have you had or are you currently experiencing a fever (above 36.6C degrees)?

Have you had any close contact with anyone who has tested positive for COVID-19 in the last 14 days?

Have you returned from any interstate or overseas travel in the last 14 days?

NONE OF THE ABOVE

Agreement *

I have understood, read and completed this form truthfully to my knowledge. I knowingly and willingly consent to having services at Ananda Wellness Australia during the COVID-19 pandemic. I confirm to my knowledge that I, my household or social bubble have not been in contact with anyone that has had symptoms of COVID-19 in the last 14 days or anyone who has been self-isolating. I consent for the services to be carried out which involves a staff member of the team being in physical contact with me with less than 2 metres distance. To prevent the spread of the virus and protect each other, I confirm that I will strictly follow guidelines. If guidelines are not strictly followed, I understand that Ananda Wellness Australia has the right to cancel the appointment with the full cost of the service being charged and any other paid costs being non-refundable. I confirm that I release the staff member performing the service and as a business, Ananda Wellness Australia, from any and all liability for the unintentional exposure or harm due to COVID-19.

Thank you!

Privacy Policy

This information will be kept confidential and not given to any third party.

want to contact us?

Rear 137 Station Street, Fairfield. VIC 3078. Australia.

team.anandawellnessaus@gmail.com

+61 401 742 329

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