Covid-19 Risk Consent Form

Explanation of face to face services during the Coronavirus Crisis

Your practitioner completed a Clinical Triage and Risk Assessment, which helped them determine that your condition warrants a face to face consultation, despite the risk of coronavirus infection, and all precautions to prevent and control the risk of infection must be observed for this consultation to take place.

Your consultation will be with a qualified practitioner. It will include detailed discussions about your condition and a physical examination that may require the practitioner to touch you or be close to you; it may be necessary to remove articles of clothing to allow examination. If you experience discomfort during the examination, please report this to your practitioner, they will not ask you to perform any task which is not appropriate for, or relevant to, your injury/condition.

The practitioner will be wearing personal protective garments and equipment during the consultation and will maintain a minimum 2m distance from you, unless closer contact or observation is required for short periods of time. Please ensure that you maintain this distance yourself during the consultation. You are encouraged to wear a face covering during the consultation, this can be supplied by your practitioner for a small charge which will be added to the charge at the end of your appointment.

Following your assessment, a course of treatment may be recommended, which may be provided virtually by telephone or video calling. Your practitioner will discuss and agree treatment plans with you; these will always include self-management strategies, and exercises for you to do at home on a regular basis. Because of the risk of coronavirus infection, it is important that we make you aware that there is an increased risk of coronavirus infection if you choose to attend a face to face consultation, despite all precautions being taken.

Your declaration

* I have been made aware of the virtual first guidelines Parkhouse Osteopathy are operating during the COVID-19 pandemic and that all non-urgent care is conducted virtually where possible
* I understand COVID-19 has a long incubation period, during which carriers of the virus may not show symptoms and still be highly contagious.
* I confirm I have read and understand the content of this consent form, including that there is a risk of coronavirus infection in attending a face to face consultation
* I confirm that I am willing to accept that risk and any consequences thereof
* I agree to undertake a face to face assessment despite this risk
* I confirm that I have not had any of the following symptoms of COVID-19 listed within the last 14 days or knowingly been in contact with anyone with these symptoms:
* A new cough that’s lasted for an hour
* Coughing more than usual/three or more episodes of coughing in 24 hours
* A high temperature (>37.5°) or feeling hot to the touch in chest/back
* Feeling warm, cold or shivery
* Difficult breathing
* A loss of, or change in normal sense of taste or smell (anosmia)
* Nausea, vomiting or diarrhoea
* Episodes of confusion
* Unexplained reduced mobility