Oakalls Physiotherapy Consent Form

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 *
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 at The Oakalls Physiotherapy Clinic. *
I Confirm that I have reached a Mutual agreement to attend a Face-to-Face appointment with a physiotherapist @ The Oakalls Physiotherapy Clinic *
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) *
I confirm that I have received & read the Patient Information leaflet on the day of the procedure *
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? *
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 *
I agree for you to store my personal information and contact me by the most appropriate way, either by eg txt, email or phone *
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 *
COVID-19 SYMPTOM CHECKER
Have you had the COVID 19 Vaccine? IF yes, date of your first and/or second dose of the vaccination (otherwise N/A) *
In the last 28 days, have you or any members of your household had a positive COVID 19, if the answer is Yes, can you please confirm the date of the first onset of symptoms? *
In the last 14 days have you or any members of your household been within 2 meters to someone who is known to have COVID-19 *
If the answer is Yes to the above 2 questions, have you completed 14 full days of isolation?
In the last 14 days have you travelled outside the UK outside the government airbridge agreement? *
If the answer is yes to the above question, then have you completed x10days of quarantine? *
In the last 14 days have you or any members of your household experienced any of these symptoms below that are NOT NORMAL or NEW for you or for them? Please answer Y/N *
1. A New Persistent Cough? *
2. A High Temperature? (hot to touch chest or back, higher than 38c) *
3. A new Change or Loss in Sense of Smell or Taste? *
4. Congested or Runny nose? *
5. Sore throat? *
6. Sneezing? *
7. Headache? *
8. Nose Bleed? *
9. Body aches? *
10. Chills? *
11. Fatigue? *
12. Nausea or vomiting? *
13. Diarrhoea? *
14. Shortness of Breath/Chest Tightness/Difficulty breathing? *
Any additional comment relating to the above questions, if needed.
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Signature *

Clear
Date *

Month Day Year
Date
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Oakalls Physiotherapy Informed Consent For Face-to-Face Consultation During the COVID-19 Pandemic