Patient Information and Consent Form
Risk of Coronavirus (COVID-19) Transmission at King Street Chiropractic and Natural Health Centre
*This Form is in addition to the consent form for chiropractic examination and treatment*
The Government published a Statutory Instrument on 26th March 2020, no. 350 ‘The Health Protection (Coronavirus, Restrictions) (England) Regulations 2020’ confirming that it is lawful for a chiropractic practice to remain open. It further defines those people who are recognised as vulnerable for the purposes of document.
King Street Chiropractic and Natural Health Centre have conducted a thorough risk assessment to ensure adequate levels of safety at this clinic are implemented and maintained. We are following the most up-to-date Government and Public Health England guidance and put in place stringent patient triage, hygiene, sanitation and infection control protocols to protect our patients and team members. Despite these precautions, there is a risk of transmission of the Coronavirus (COVID-19) and it is important that you understand the risk. We have provided the information below to help you decide if you wish to continue with your care at King Street Chiropractic and Natural Health Centre and remind you that you are under no obligation to do so.
Precautions that King Street Chiropractic and Natural Health Centre have in place:
- All patients contacting us for an appointment are triaged to establish whether Covid-19 symptoms are present, if they are self-isolating, if anyone in their household has symptoms or is self-isolating, they have recently returned from overseas or they have been in contact with anyone with COVID-19 symptoms and been asked to self-isolate by NHS Track & Trace.
- We enforce a strict policy that anyone with any COVID-19 symptoms must stay away from the clinic.
- A second triage is conducted at the Clinic, including a temperature check.
- A strict cleaning, sanitation and infection control protocol is adhered to – Please ask if you would like to see this document.
- All team members at King Street Chiropractic and Natural Health Centre adhere to the social distancing guidance issued by the Government.
- The layout of the practice has been adapted to maintain social distancing.
- Patients waiting are restricted to one at any time and a 2-metre distance will be enforced between patients and non-clinical team members.
- Chiropractors and Clinical Staff will be wearing Personal Protective Equipment (PPE) for your protection.
- You may be asked to wear a face-covering when attending the clinic.
King Street Chiropractic and Natural Health Centre are committed to ensuring that every measure is in place to minimise the risk of exposure to COVID-19, we cannot guarantee there is no risk to you as a result of attending the clinic.
Eligibility for Care
We are unable to offer face-to-face appointments to the following people: If you are self-isolating – until your isolation period is over and you have no symptoms; you have COVID-19 symptoms (whether diagnosed by test or not); if you are living with someone with COVID-19 symptoms (whether diagnosed by test or not); you have been in contact with anyone with suspected or confirmed COVID-19 and have been asked to self-isolate for 14 days by the NHS Contact Tracing Service, or you have recently returned from a country where the UK Government has imposed a 14 day self-isolation period.
As shielding has now come to an end, we are now able to accept patients from the vulnerable “High Risk” and “Moderate Risk” groups as defined by the NHS unless you have been specifically told by your GP or consultant that you should continue to shield.
If you do have any underlying health condition, we ask that you notify us so that we can take this into consideration when carrying out our risk assessment.
Consent to receive care at King Street Chiropractic and Natural Health Centre
- I have answered all questions (triage) relating to my potential exposure to Coronavirus (COVID-19) truthfully.
- I understand that there is a potential risk of transmission of Coronavirus (COVID-19) as a result of attending the clinic and/or receiving treatment.
- I have had the opportunity to ask all the questions I wish to, and all my questions have been answered to my satisfaction.
- I have read, agreed to and understood the statements above relating to Coronavirus (COVID-19) risk and consent to receive care at King Street Chiropractic and Natural Health Centre.
- I understand and agree that I will need to give separate consent regarding my chiropractic care.
For patients with GP/ Consultant approval or referral:
- I confirm that I have approval from my GP/ Consultant to receive chiropractic care Please tick
Patients Name: _________________________________________
Patients Signature: _________________________________________
Date: _________________________________________