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COVID Consent Form

Patient Information and Consent for Face-Face treatment during COVID pandemic

The clinicians at Fisiosportstherapy follow all guidelines set out for them by their governing bodies in relation to face-to face contact with patients during the COVID outbreak.

It is important that you are aware of the changes we have made to make the clinic as safe as possible. By agreeing to face to face contact it is not always possible to maintain a 2 metre distance. We have therefore made a few changes to the clinic and the way we work.

Additional Safety measures to protect Patients and Staff include:-

  • Increased ‘virtual’ consultations made available to non-urgent patients.

  • Telephone risk factor screening of patients prior to offering a face to face appointment.

  • Greater time between patients to allow for cleaning of consulting rooms

  • Reduced usage of the waiting room by asking patients to wait in car or outside of the clinic until their appointment time.

  • Less clinicians in the clinic and therefore less patient ‘footfall’.

  • PPE worn by clinicians whilst working.

  • Patients are required to wear a face covering when inside the clinic.

  • Increased signage on social distancing (where appropriate)

  • More sanitisation stations located around the clinic

  • One in and One out policy to minimise patient numbers in the clinic.

  • Increased frequency of cleaning contractors

It is important to acknowledge that the risk of COVID-19 transmission cannot be eliminated and that ALL patients should consider their NEED for treatment very carefully before requesting ‘Face-to Face’ contact.

COVID - 19 Consent Form

IMPORTANT – It is the right of the clinician to deny ‘Face-to-Face’ treatment if they deem the risks to either party is too great. 

Medical checklist – This is to confirm and sign that you have no current symptoms of COVID-19 or are within a high risk medical group. This is required before a face to face contact is considered. On completion of this form you MAY be contacted by a member of our team.

I knowingly and willingly consent to a face to face appointment during the COVID-19 pandemic.
I understand that COVID-19 has a long incubation period during which virus carriers may not show symptoms and it is impossible to determine who has it within current testing capacity
Face to face appointments should be limited to those that can not be performed virtually, that are in significant pain or have significant dysfunction that are causing limitation to your ability to work or perform activities of daily living or emotional/psychological stress. I confirm I am seeking an appointment that meets this criteria.
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, also have not tarveled oustide of the uk in the past 14 days.
I confirm that I am not in the clinically extremely vulnerable category and therefore advised to shield by the government.
I confirm I have not been in close contact with anyone with confirmed COVID-19 without wearing appropriate PPE.
I have had the opportunity to ask all the questions I wish to, and all of my questions have been answered to my satisfaction
I solemnly and sincerely declare that the information I have provided is true and correct.

Thanks for submitting!

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