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Consent Form for 'Face to Face' appointment
For use during Covid-19 pandemic management

You must fill in and submit this form prior to your appointment if you have not been to the clinic before July 2020.  This is a legal requirement 

(Form filling time: 5 minutes)

Personal Details

>> Full details of our GDPR  and Data Protection policy.

Covid -19

To keep you safe during the Covid-19 pandemic management, we need to make sure that any face to face clinic appointments are both appropriate and safe.  

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Face to face appointments should be currently limited to:

- those whose treatment cannot be performed effectively with a video appointment

- those who have pain or dysfunction which is limiting work, exercise, activities of daily living or    affecting them emotionally or psychologically.

Medical Screening

Have you have a fever in the last 14 days?
Do you now, or have you recently had, a persistent dry cough?
Have you lost sensations of taste or smell?
Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or who has coronavirus-type symptoms?
Have you been told to stay at home, self-isolate or self-quarantine?
Do you or anyone that you live with fall into the 'clinically extremely vulnerable' categories as defined

here

Consent for treatment

I understand that because my treatment may involve close physical proximity and touch over a prolonged period of time, there may be an elevated risk of disease transmission, including Covid-19.

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I have read the clinic protocol and I am happy with the measures that have been taken mitigate these risks

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I understand that my details may be used to contact me if required as part of the 'Track and Trace' system.

Thanks for submitting!

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