Oakalls Physiotherapy Informed Consent For Face-to-Face Consultation During the COVID-19 Pandemic
Any visit to healthcare premises carries some risk of transmission of the coronavirus either through close contact with an infectious person or indirectly through touching infected surfaces. Following our risk assessments, we have implemented measures to reduce this through cleaning, maintaining social distancing where possible and the use of PPE (advised by public health Englands "safe ways of working during COVID-19 pandemic") by staff and clinicians, based upon government guidelines. However, the risk of transmission cannot be entirely eliminated and some clinical procedures carry greater risks. Please Fill in your appropriate details and answer Yes or No to the following Q's
CONSENT & NEED FOR CARE
I confirm I have completed the initial telephone COVID-19 Screening & Virtual triage with a physiotherapist & discussed the best & most appropriate care pathway for me
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I understand the risk of transmission of COVID-19 & I have had adequate opportunity to ask questions & discuss any concerns. I have also been told of the safety measures in place @ The Oakalls Physiotherapy Clinic
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I Confirm that I have reached a Mutual agreement to attend a Face-to-Face appointment with a physiotherapist @ The Oakalls Physiotherapy Clinic
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I understand & consent to wearing PPE (face mask provided)
I understand & consent to follow all infection control measures.
I consent to a Face-to-Face consultation & understand that this may include close physical contact (less than 2 meters)
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I confirm that I have received & read the Patient Information leaflet for on the day procedure
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On the day of your assessment the physiotherapist will explain & provide information on treatment options and fully explain risks v benefits & the best treatment options for your symptoms. This will be by mutual agreement, & may include; Exercise Prescription, Acupuncture, Radial shockwave, Ultra-Sound or Manipulation or Soft Tissue Massage. Do you agree to this?
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I give my consent to attend a Face to Face appointment @ The Oakalls Physiotherapy Clinic during COVID-19 pandemic & I am fully aware of the associated risks
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I agree for you to store my personal information and contact me by the most appropriate way, either by eg txt, email or phone
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Third party information sharing - There are times when we will need to share your personal details with relevant Health Care Professionals, such as your; Gp/Consultant/Radiologist/Other Allied Healthcare professionals, Insurance Companies, Personal Trainers & Sports Coaches. However, mutual agreement would always be obtained first, do you agree to this
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Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Area Code
Phone Number
Signature
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Clear
Date
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Month
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Day
Year
Date
Submit
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