Nat Broad Physio Penrith cumbria

COVID-19 Appointment Agreement Form

    Mandatory COVID-19 Screening consent form
    Please fill out this quick survey ahead of your appointment to help everyone stay safe. We can confirm at the point of booking your clinician has no Covid-19 symptoms. They will be wearing the appropriate PPE under strict PHE guidance. Clients are required to wear a mask and follow the strict Covid-19 protocols in place in the clinic. Video appointments are available if you would prefer not to attend the clinic, please make urgent contact with reception as we may need to alter your appointment slot. We ask for your understanding at this time, as we continue to be guided by strict governing body and PHE guidelines. Please be aware our guidance as a medical facility may be different from the national guidelines.
    I consent to adhering to the clinic’s strict health and safety guidance including obtaining a PCR test if requested.
    I knowingly and willingly consent to have face to face Physiotherapy Treatment completed during the COVID-19 pandemic. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I understand I am not permitted to attend the appointment should there be cases within my household.

    Have you now or at any time in the last 14 days, had any of the following symptoms, please tick all that apply. (Please answer honestly, some of these may affect what treatment we are safely able to give you):

















    **Result:*

    Have you had any of the following in the last 72 hours (3days)?

    1.
    2.