Covid-19 Declaration

MANDATORY HEALTH & TRAVEL DECLARATION

To protect and safeguard the Breathing Place Community, all guests must complete the following declaration form prior to every visit to Breathing Place without exception. Your data and answers to this declaration will be used by Breathing Place for the sole purpose of ensuring health and safety of our guests, staff and to facilitate contact tracing.

Your Name (required)

Your Email (required)

Telephone (required)

Enter Class Title/Physical Therapy, Date & Time (required)

Have you been fully vaccinated?
—Please choose an option—YesNo

Have travelled outside of the Republic of Ireland in the last 14 days and been asked to self-isolate on your return?
—Please choose an option—YesNo

Do you believe that you may currently have COVID-19?
—Please choose an option—YesNo

Have you had any of the following symptoms of COVID-19 in the past 14 days?

High temperature (i.e. over 37.5°c)
—Please choose an option—YesNo

A new continuous cough
—Please choose an option—YesNo

New unexplained shortness of breath
—Please choose an option—YesNo

Loss of sense of smell, of taste or distortion of taste
—Please choose an option—YesNo

If you have answered YES to any of these questions you should stay at home and contact your GP by phone for further advice. At all times - if you feel unwell stay at home.

If you have travelled outside of Ireland for any reason, or have been in contact with anyone who has, please do not come to class for 14 days.

Please (digitally) sign this form to confirm that the details above are true to the best of your knowledge and that:

I agree to abide by all social distancing and safety regulations as instructed by instructors, therapists and management of Breathing Place Yoga & Physical Therapy.

In the event of developing symptoms such as fever, cough, breathlessness, sore throat, runny nose or Covid-19 diagnosis, I agree to immediately contact Breathing Place Yoga & Physical Therapy to inform us of this.

In case of emergency, contact: