COVID Consent Form

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

The clinicians at Bodysym 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.
  • Your temperature will be taken on entering the reception area
  • Protective screens around Reception.
  • 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.

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.

Have you had a confirmed episode or have you been tested for COVID-19?
YESNO

Has anybody in your household displayed COVID-19 symptoms within the past 2 weeks?
YESNO

Have you had a cough in the last 2 weeks ?
YESNO

Have you had a Fever in the last 2 weeks?
YESNO

Are you considered to be in a vulnerable group in relation to COVID -19?
YESNO

Do you have a compromised immune system?
YESNO

Do you have a compromised respiratory system or breathing problems ?
YESNO

Have you had any type of organ replacement?
YESNO

Are you currently on chemotherapy?
YESNO

I have agreed with my Physiotherapist that a virtual appointment is not indicated?
YESNO
I have been informed of the safety measures put in place within the clinic to address the risks of COVID-19
YESNO

I understand the cleaning processes in place in treatment areas
YESNO

I understand the procedure for attending the clinic for a face to face appointment
YESNO

I have undertaken a medical checklist
YESNO


I have read the above summary of the changes that have been made in the clinic to minimise the risk of COVID-19 transmission and I am consenting to face to face treatment. I understand that I may be contacted by a member of the Bodysym team prior to my appointment.