Screening and consent form
Please tick I am aware of the Covid-19 protocols: read over phone ___ sent via e:mail ___ read on website ___
1. Have you been tested for Covid-19? Yes or No
a. If yes, have you tested positive? Yes or No
Between which dates did you have it? _______ to ________
(As long as you’ve been in self isolation for 10 days from your diagnosis and no longer have symptoms, you can come for treatment).
2. Do you have, or have you had any of these symptoms in the last 10 days? (please tick):
Fever (feeling hot to touch on your chest and back) ___
Dry, persistent cough (a lot for an hour+, 3+ coughing episodes in 24 hrs or worsening of existing cough)___
Loss of taste and smell ___
Unusual fatigue ____ shortness of breath ____ or any new rashes on your body or feet? ____
a. If you have ticked any of the above, please postpone treatment for 10 days from first symptoms.
3. Have you been in contact with anyone who has been diagnosed with Covid-19 or who has any of the above symptoms in the last 2 weeks? Yes or No
a. If yes, please postpone your appt and self-isolate for 14 days from first contact with this person
4. Are you or anyone you live with clinically vulnerable or extremely vulnerable? Yes or No
a. If yes, what is the reason? solid organ transplant recipients ___ people with specific cancers ____ bone marrow or stem cell transplants in last 6 months ____ taking immunosuppressing drugs ____ severe respiratory conditions (cystic fibrosis, severe asthma, COPD) ____ rare diseases (severe combined immunodeficiency, homozygous sickle cell) _____ pregnant women with significant heart disease _____ other _____
b. If yes for yourself only book treatment if not having treatment would cause detrimental deterioration to your condition. Ask to be scheduled at the start of the day and use visors and face coverings even if social distancing is lifted.
c. If yes for a family member treat but both wear face coverings.
5. Do you have any allergies any particular cleaning products? Yes or No If yes, what? __________________________
6. Do you have any hearing issues that may make it difficult to hear my voice behind a mask? Yes or No
Please inform the practice if you develop any of the above symptoms or test positive with COVID-19 within 14 days of leaving appointment.
Consent for treatment
I understand that, because my treatment does/may involve touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including Covid-19.
I give my consent to receive treatment from this practitioner, Lucy Thompson
and for my details to be shared for track and trace purposes, which will be kept in line with GDPR legislation.
I am the Patient ___ Parent/guardian/carer ___
Signature: ________________________________Date: _________________