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:

Summertown

Second Floor, 228 Banbury Rd, Summertown, Oxford OX2 7BY

Iffley Road

Iffley Rd, Oxford OX4 1EQ

Bicester

12 Kings End, Bicester OX26 6DT

Woodstock

32 New Rd, Woodstock OX20 1PB

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