Covid 19 Consent Form

Name

First NameLast Name

Phone Number

Area CodePhone Number

E-mail

example@example.com

Appointment Date

MonthDayYear

Type a question*

	Yes	No
Do you have a high temperature
Have you had a fever in the last 10 days
Do you now or have you recently had a persistent dry cough
Have you lost your sense of smell or taste
Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has coronavirus-type symptoms? And if so was your PCR test positive?
Have you been told to stay home, self-isolate or self-quarantine?
Do you or anyone that you live with fall into the “critically vulnerable” or “clinically extremely vulnerable categories? (defined below)
Have you travelled abroad in the last 14 days?
Do you have any other symptoms that may mean you have a Covid-19 infection?
Have you had sickness or diarhorrea?
Have you taken a lateral flow test or PCR recently and had a positive result

Do you have a high temperature

YesNo

Have you had a fever in the last 10 days

YESNO

Do you now or have you recently had a persistent dry cough?

YESNO

Have you lost your sense of smell or taste ?

YesNo

Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has coronavirus-type symptoms?

YESNO

Have you been told to stay home, self-isolate or self-quarantine?

YESNO

Do you or anyone that you live with fall into the “critically vulnerable” or “clinically extremely vulnerable categories? (defined below)

YesNo

Clinically vulnerable people

People in this category of risk include:

Anyone aged 70 and older (regardless of medical conditions)
Anyone under 70 with an underlying health condition (that is, anyone instructed to get a flu jab as an adult each year on medical grounds) – such as:
chronic (long-term) mild to moderate respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), emphysema or bronchitis
chronic heart disease, such as heart failure
chronic kidney disease
chronic liver disease, such as hepatitis
chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis (MS), a learning disability or cerebral palsy
diabetes
a weakened immune system as the result of conditions such as HIV and AIDS, or medicines (such as steroid tablets )
being seriously overweight (a body mass index (BMI) of 40 or above)
pregnant women

Clinically extremely vulnerable people

People in this category of risk include:

Solid organ transplant recipients.
People with specific cancers:
people with cancer who are undergoing active chemotherapy
people with lung cancer who are undergoing radical radiotherapy
people with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment
people having immunotherapy or other continuing antibody treatments for cancer
people having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
people who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs
People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe chronic obstructive pulmonary disease (COPD).
People with rare diseases that significantly increase the risk of infections (such as severe combined immunodeficiency (SCID), homozygous sickle cell).
People on immunosuppression therapies sufficient to significantly increase risk of infection.
Women who are pregnant with significant heart disease, congenital or acquired.
More information about who has been classed as clinically extremely vulnerable is available on the NHS Digital website.

Have you travelled abroad in the last 14 days?*

Do you have any other symptoms that may mean you have a Covid-19 infection?

YESNO

Please read and agree

Today's Date

DayMonthYear

I understand that, because my treatment may involve touch and close physical proximity over an extended period of time, there maybe an elevated risk of disease transmission, including Covid-19. I give my consent to receive treatment from Sarah Stamp at Olive Tree, Brackley.

Signature