Consent form COVID-19

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

Consent Form COVID -19

Personal Details

Face to Face Consent Form

I knowingly and willingly consent to a face to face appointment during the COVID-19 pandemic. *
I understand that COVID-19 has a long incubation period during which virus carriers may not show symptoms and it is impossible to determine who has it within current testing capacity. *
I have been made aware of the guidelines that under the current pandemic a virtual first approach will be followed and, if appropriate, a session should be done online where possible. *
Face to face appointments should be limited to those that can not be performed virtually, that are in significant pain or have significant dysfunction that are causing limitation to your ability to work or perform activities of daily living or emotional/psychological stress. I confirm I am seeking an appointment that meets this criteria. *
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 have not travelled outside of the UK in the past 14 days. *
I confirm that I am not in the clinically extremely vulnerable category and therefore advised to shield by the government. *
I confirm I have not been in close contact with anyone with confirmed COVID-19 without wearing appropriate PPE. *
I have had the opportunity to ask all the questions I wish to, and all of my questions have been answered to my satisfaction. *
I solemnly and sincerely declare that the information I have provided is true and correct and I make this solemn declaration conscientiously believing the same to be true. If any person should suffer as a result of the information being found to be untrue or false, then I am aware that I can be prosecuted for making a false declaration. *