Consent form COVID-19

We need you to complete this form prior to your face to face appointment.

First Name

Last Name

Sur Name

I have not had any of the following symptoms in the last 7 days: fever, shortness of breath, loss of sense of taste or smell, dry cough, runny nose or sore throat and if I have, I have followed all government guidance.

False True

To the best of my knowledge, I have not been in close contact with anyone with confirmed COVID-19 in the last 7 days, and if I have, I have followed all government guidance.

False True

I understand that coronoavirus may not cause symptoms in some people and is currently causing a pandemic which means healthcare services are required to operate differently.

False True

I am aware of the requirements for social distancing, hand sanitizing, wearing a face covering and for contactless payments, if able, when at the clinic.

False True

I understand that the therapist/instructor will wipe down all surfaces before and after my attendance and they will be wearing PPE as set out by health authorities.

False True

I am aware why my clinical need for healthcare cannot be met by a telephone or video consultation, and I have had the opportunity to ask all the questions I wish to and they have been answered to my satisfaction.

False True

I agree to attend a face to face appointment during the COVID-19 pandemic.

False True

If you answered no to any of the questions above, please provide detail:

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CHOOSE LOCATION:

North Oxford, Summertown

Second Floor Summertown Pavilion, 18-24 Middle Way OX2 7LG

Central Oxford, NorthGate

NorthGate Health Centre, 15 Market Street, Oxford OX1 3EF

Bicester

Bicester Lesiure Centre, Queens Avenue OX26 6NR

Woodstock - CLOSED

32 New Rd, Woodstock OX20 1PB

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If you have any questions please do not hesitate to contact us using the form below.

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Consent form COVID-19

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North Oxford, Summertown

Central Oxford, NorthGate

Bicester

Woodstock - CLOSED

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