Thankfully the consent form below is not currently being used.
Consent form - completed by patient at clinic
Personal Details
Name:
Address:
I confirm that I have not had any of the following symptoms in the last 14 days: fever, shortness of breath, loss of sense of taste or
smell, dry cough, runny nose or sore throat.
Yes No
I confirm that I am not in the clinically extremely vulnerable category and therefore advised to shield at home by the government.
Yes No
I confirm that to the best of my knowledge, I have not been in close contact with anyone with confirmedCOVID-19 in the last 14 days.
Yes No
I understand that coronavirus may not cause symptoms in some people and is currently causing a pandemic which means healthcare services are required to operate differently
Yes No
I confirm I have been made aware of physiotherapy guidelines that require a telephone/video triage appointment to be conducted before I can attend in person.
Yes No
About my Visit:
I confirm I am aware of the clinic’s requirement for social distancing in the clinic.
Yes No
I confirm I am aware of the clinic’s requirement for hand decontamination in the clinic:
Yes No
I confirm I am aware if the clinic requires me to wear a face-covering whilst inside the clinic[1]:
Yes No
I confirm I have been told about the cleaning of the clinic room before/after my attendance:
Yes No
I confirm I am aware of the clinic’s requirement for contactless payment
Yes No
I understand that my physiotherapist is required to wear PPE as set by Public Health authorities during my appointment and this is not optional for them.
Yes No
About my Clinician:
They have confirmed they have not had any of the following symptoms in the last 14 days: fever, shortness of breath, loss of sense of taste or smell, dry cough, runny nose or sore throat:
Yes No
They have confirmed that to the best of their knowledge, they have not been in close contact with anyone with confirmed COVID-19 in the last 14 days.
Yes No
They have discussed with me the reasons why my clinical need for healthcare cannot be met by a telephone/video consultation.
Yes No
I have had the opportunity to ask all the questions I wish to, and all of my questions have been answered to my satisfaction. Use space below to record details:
I agree to attend a face to face appointment during the COVID-19 pandemic.
Yes No
Signed Patient ………………………………………………………………………..
OR [delete as applicable]
Signature of person with parental responsibility / person legally entitled to sign on behalf of a person who lacks capacity
………………………………………………………………………………………………
Signed Therapist……………………………………………………………………….
Date: …………………
[1][1] Exemptions to wearing face masks may apply.