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Physiotherapy
Paediatric Physiotherapy
ONLINE Appointments
Sports Injury Treatment
Hand Clinic
Pelvic Health Clinic
Oncology Physiotherapy
Sports Massage
Gait Assessment
Online & Studio Group Classes
Class Schedule
All Locations
Oxford (Summertown)
Oxford (Iffley Road)
Bicester Kings End
Woodstock
Contact
Follow us
About
FAQs
Join Us
News
Meet the Team
Prices
Services
Physiotherapy
Paediatric Physiotherapy
ONLINE Appointments
Sports Injury Treatment
Hand Clinic
Pelvic Health Clinic
Oncology Physiotherapy
Sports Massage
Gait Assessment
Online & Studio Group Classes
Class Schedule
All Locations
Oxford (Summertown)
Oxford (Iffley Road)
Bicester Kings End
Woodstock
Contact
01865 311686
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Consent form COVID-19
Consent form COVID-19
We need you to complete this form prior to your face to face appointment.
Consent Form COVID -19
Personal Details
Title
*
First Name(s)
*
Surname
*
Face to Face Consent Form
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.
*
No
Yes
If you answered no to any of the questions above, please provide detail:
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