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Patient Covid – 19 Check List

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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
(dd/mm/yyyy)
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.
I confirm that if I am unwell, or have been told to self-isolate, I will inform the clinic and will NOT attend.
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.
I confirm I am aware of the clinic’s requirement for social distancing in the clinic.
I confirm I am aware of the clinic’s requirement for hand decontamination in the clinic:
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:
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.
Clear Signature
Signature of person with parental responsibility / person legally entitled to sign on behalf of a person who lacks capacity

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Write Your Review

We’re so sorry to hear that you aren’t happy with our service. Your feedback is really important to us and we do all we can to make sure we are constantly improving. Please leave your feedback for us below and we’ll get back to you to see what we can do to resolve any issues you may have.

Write Your Review

We’re so sorry to hear that you aren’t happy with our service. Your feedback is really important to us and we do all we can to make sure we are constantly improving. Please leave your feedback for us below and we’ll get back to you to see what we can do to resolve any issues you may have.