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.

Your Name (required)

Your Email (required)

Date of Birth (required)

Address

Phone Number (required)

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):

Cough YesNo
Worsening chronic cough YesNo
Sore throat YesNo
Shortness of breath YesNo
Difficulty breathing YesNo
Change in sense of taste or smell YesNo
Sneezing YesNo
Chills/Fever YesNo
Headache YesNo
Unexplained fatigue or malaise YesNo
Runny nose YesNo
Difficulty swallowing YesNo
Nausea/vomiting, diarrhoea, abdominal pain YesNo
New unexplained rash (At any point since the start of the Pandemic)YesNo
Muscle aches that feel like flu (At any point since the start of the Pandemic) YesNo
Breathlessness going upstairs (At any point since the start of the Pandemic) YesNo
None of the above symptoms YesNo

Have you been in close contact with anyone with any of the above symptoms or confirmed COVID-19 in the last 14 days YesNo

Have you been outside the UK in the last 14 days? YesNo

If Yes, have you had a PCR test? YesNo **Result:* PositiveNegative

I confirm I am aware of the clinic’s requirement for social distancing, hand-decontamination and that my clinician is required to wear PPE as set by PHE in the clinic. I confirm I am aware the clinic requires me to wear a face-covering whilst inside the clinic YesNo

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

1. Lateral Flow Test YesNo | **Result:** PositiveNegative
2. PCR YesNo | **Result:** PositiveNegative

Have you had a vaccine / flu jab in the last 48 hours? YesNo

If Yes, have you had any reaction? Please comment what symptoms as we may need to alter your appointment.

I have answered all questions honestly, and consent to attending a face-to-face appointment during the COVID 19 Pandemic. I also consent to adhering to the clinic protocol and understand this is in place for both my and the staff’s safety. I confirm I will notify the clinic at the first sign of any of the above symptoms for all future appointments. YesNo
Sign Your Name and date (required)