Covid-19 Consent form
Covid-19 Consent form

Please complete the following Covid-19 consent form prior to your appointment:

    1. I, knowingly and willingly consent to have face to face Physiotherapy treatment completed during the COVID-19 pandemic. I understand that Covid-19 is a highly contagious virus and has a long incubation period during which carriers of the virus may not show symptoms.YesNo


    2. I have been made aware of the guidelines that under the current pandemic all non-urgent Physiotherapy care is done remotely where possible. Physiotherapy treatment is limited to those with significant discomfort and pain.YesNo


    3. I confirm that I have NOT had any of the following symptoms of COVID-19 listed below within the last 21 days and have NOT knowingly been in contact with anyone with these symptoms:

    • 3.1 Fever (tempreture above 37.8 deg) YesNo

    • 3.2 New and persistent cough YesNo

    • 3.3 Shortness of breath YesNo

    • 3.4 Loss of sense of taste or smell YesNo

    • 3.5 Runny nose YesNo

    • 3.6 Sore throat YesNo


    4. I am aware that Public Health England recommends social distancing of at least 1 meter between people who are not members of the same household, and this is not possible with face to face physiotherapy. I confirm that I would still like to proceed with an appointment at the clinic.YesNo


    5. I solemnly and sincerely declare that the information I have provided is true and correct and there has been no changes since the virtual screening.YesNo


    6. I confirm that I am happy to share my contact information for TEST & TRACE when required.YesNo

    Please answer all questions

    START YOUR JOURNEY TO RECOVERY TODAY

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    START YOUR JOURNEY TO RECOVERY TODAY

    BOOK AN APPOINTMENTOR CALL 07568 513 546

    START YOUR JOURNEY TO RECOVERY TODAY

    BOOK AN APPOINTMENTOR CALL 07568 513 546