COVID Screen Form questions.



  • I have read the latest information. I am not in the High risk category.COVID-19 NHS Link.
  • No one in my household is in the high risk category defined by the above link
  • I have not had a high temperature, persistent cough or had loss or change to your sense of smell or taste in the last 14 days
  • I will not attend if anyone in my household has had any of the symptoms identified by the NHS link above within the last 14 days.
  • I will wait in my car until collected by my Osteopath. To reduce contact with other patients.
  • I will bring my own face mask. If I require one I will contact the clinic before my appointment with my Osteopath. (These can be supplied.)
  • I understand that on entry to the clinic I will wash my hands in soap and hot water for 20 seconds and dry on paper towels. I will use alcohol hand sanitiser on my way out.
  • I understand that Osteopathic Consultancy will be using anti-viral surfaces wipes to clean all surfaces that I come into contact with.
  • The appointment will be 1v1 with no one else in the clinic room. If the patient is under 18, one guardian is allowed in the clinic room
  • I understand that the Osteopath will be wearing PPE- Mask, Apron and Gloves.
  • Osteopathic Consultancy will replace the pillow case each time and I will not have a plinth cover.
  • I agree to these ongoing procedures for this and future appointments.
  • I agree to notify Osteopathic Consultancy if I or anyone in my household gets COVID 19.
  • I will avoid touching any surfaces when I am in the clinic.
  • I understand that my Osteopath and myself may be infected with Covid-19. We are both taking appropriate precautions to safeguard against the chances of transmission.
  • I consent to treatment from Osteopathic Consultancy and understand the risks of Coronavirus. I appreciate that all precautions are in place to minimise this risk.
  • I accept the above statements and I will agree and accept the procedures are in place for all our safety.
  • I am aware there is a 24 hour cancellation policy and I will liable for payment if I cancel within 24 hours

Have Your Contact Details Changed ?

yesno






Has your general medical health or medication changed ?

yesno





































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