Personal Details
Name:
Address:
Telephone :
About Me:
I confirm that I have not had any of the following symptoms in the last 14 days: fever, shortness of breath, loss of sense of taste or smell, dry cough, runny nose or sore throat.
Yes No
I confirm that I am not in the clinically extremely vulnerable category and therefore advised to shield at home by the government.
Yes No
I confirm that to the best of my knowledge, I have not been in close contact with anyone with confirmed COVID-19 in the last 14 days.
Yes No
I understand that coronavirus may not cause symptoms in some people and is currently causing a pandemic which means healthcare services are required to operate differently.
Yes No
I confirm I have been made aware of physiotherapy guidelines that require a telephone/video triage appointment to be conducted before I can attend in person.
Yes No
About my Visit:
I confirm I am aware of the clinic’s requirement for social distancing in the clinic.
Yes No
I confirm I am aware of the clinic’s requirement for hand decontamination in the clinic:
Yes No
I confirm I am aware that the clinic might require me to wear a face-covering whilst inside the clinic (exemptions may apply):
Yes No
I confirm I have been told about the cleaning of the clinic room before/after my attendance:
Yes No
I confirm I am aware of the clinic’s requirement for contactless payment
Yes No
I understand that my physiotherapist is required to wear PPE as set by Public Health authorities during my appointment and this is not optional for them.
Yes No
About my Clinician:
They have confirmed they have not had any of the following symptoms in the last 14 days: fever, shortness of breath, loss of sense of taste or smell, dry cough, runny nose or sore throat.
Yes No
They have confirmed that to the best of their knowledge, they have not been in close contact with anyone with confirmed COVID-19 in the last 14 days.
Yes No
They have discussed with me the reasons why my clinical need for healthcare cannot be met by a telephone/video consultation.
Yes No
I have had the opportunity to ask all the questions I wish to, and all of my questions have been answered to my satisfaction. Use space below to record details:
I agree to attend a face to face appointment during the COVID-19 pandemic.
Yes No
Signed Patient ………………………………………………………………………
OR [delete as applicable]
Signature of person with parental responsibility / person legally entitled to sign on behalf of a person who lacks capacity ………………………………………………………………………………………………
Signed Therapist………………………………………………………………………
Date: …………………
