Consent form COVID-19

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. *

I confirm that I am not in the clinically extremely vulnerable category and therefore advised to shield by the government. *

I confirm, to the best of my knowledge, I have not been in close contact with anyone with confirmed COVID-19 without wearing appropriate PPE. *

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. *

I confirm that 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. *

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. *

I have been informed that my clinician has not had COVID-19 related symptoms or been in contact with anyone, to the best of their knowledge, with confirmed COVID-19 in the last 14 days. *

It has been discussed with me why my clinical need for healthcare cannot be met by 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. *

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