Patient Covid - 19 Check List - Ashbourne & Hilton Physiotherapy & Sports Injury Centre

Patient Covid - 19 Check List

You have a Face to Face appointment scheduled. As part of the current Covid - 19 procedures we require you to complete the following screening questions. This is a legal requirement and is to ensure the safety of yourself and our staff. Please check that all your information is correct before submitting

Name *

First

Last

Date of Birth *

(dd/mm/yyyy)

Email *

I confirm that I have not had any cold or flu symptons, temperature or a loss of sense of taste or smell in the 10 days prior to my appointment. *

Yes
No

I confirm that if I am unwell, or have been told to self-isolate, I will inform the clinic and will NOT attend. *

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 10 days and have not had a positive Covid test in that time. *

Yes
No

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 I am expected to wear a face covering while at the clinic in line with Public Health England guidance for Healthcare Providers¹: *

Yes
No

Exceptions to wearing face mask may apply.

I understand that my therapist is required to wear PPE as set by Public Health authorities during my appointment. *

Yes
No

Signed Patient *

Clear Signature

Signature of person with parental responsibility / person legally entitled to sign on behalf of a person who lacks capacity

Date *

Patient Covid – 19 Check List

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