COVID Consent Form

UPDATED: April 2021

Please Complete and Submit the Covid-19 Consent Form below before attending your appointment. You only need to do this once, prior to your first appointment.

Following our insurance and government guidelines, we are happy to announce we can run physical consultations for clients non-covid-19 and clear of “covid 19 related symptoms” for 14 days.

If you have any of the symptoms below, or have had a fever or cold & flu like symptoms in the last 7 days, please stay at home and reschedule your appointment:

• High temperature – this means you feel hot to touch on your chest or back. You could also measure your temperature.
• New, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual).
• Loss or change to your sense of smell or taste – this means you’ve noticed you cannot smell or taste anything, or things smell or taste different to normal.

To reduce the spread of infection, we request that ALL visiting clients do the following:

• This is your responsibility to check the requirements of the country you are traveling in and to.
• All appointments will be paid for prior to attending the clinic.
• There will be a 30 minute cleaning and ventilation time prior to your appointment so please do not arrive early.
• If you require a chaperone when attending for an appointment, they may need to wait outside in their vehicle to limit the number of people in reception.
• Please bring a face mask/ covering with you and minimal personal belongings.
• Please use the hand sanitiser gel on entering and leaving the building. If you wish to wash your hands with soap and water instead, please ask reception staff.
• Your temperature will be taken with a non-contact infrared thermometer.
• You will be asked to place your belongings, clothing and footwear in a designated .
• Please cover coughs and sneezes with a tissue and bin it, or use the inside of your elbow, and then wash your hands.
• Please bring your own water with you.

What your practitioner will be doing, and how we will operate:

• Your practitioner will be wearing PPE and/or following any special measures as advised by their professional bodies/government, and this may be different for all services. If you would like to know what these are for your specific practitioner in advance of your appointment, please contact us.
• Your practitioner will have more gaps between appointments to allow for extra cleaning and sanitising measures during the outbreak.
• We are sanitising contact points in the reception area between patients.
• It may be necessary to close the clinic at short notice if we are advised to do so and/or if any staff and practitioners show any Covid-19 symptoms, or if we decide closure is of the benefit of public health at that time.

We will continue to operate under guidance from the Government, NHS & Public Health England. In addition, your practitioner will always be following advice from their professional/ regulatory bodies.

COVID Consent Form

We are also not responsible for any mistake made on the forms filled in by the patient.

Based on what is currently known about COVID-19, the spread is thought to occur mostly from person-to-person via respiratory droplets among close contacts. Close contact can occur from being within approximately 6 feet of someone with COVID-19 for a prolonged period of time.

I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious.

I understand that if I visit or live with someone in a high risk/ vulnerable category, then I should avoid close contact with others.

I understand that due to the unknowns of this virus, the number of other patients that have been in the practice and the nature of the treatments performed here, that I may have an increased risk of contracting the virus by being in the practice and receiving treatment here.

Known symptoms representative of COVID-19, according to the NHS:

>>> high temperature – this means you feel hot to touch on your chest or back (you do not need to measure your temperature).

>>> new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual).

>>> loss or change to your sense of smell or taste – this means you’ve noticed you cannot smell or taste anything, or things smell or taste different to normal.

I have read and understood the information detailed above. *YesNo

I do not display or currently have any of the symptoms that are representative of COVID-19, which are outlined above *YesNo

I am not 'shielding' or living with someone in the high risk/ vulnerable category *YesNo

To the best of my knowledge, I have not had close contact with an individual diagnosed with COVID-19 in the past 14 days *YesNo

I consent to receive treatment during the COVID-19 outbreak, and agree to cancel any future appointments should I develop symptoms *YesNo

Name *

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Contact Number *

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