Exmoor Osteopathy Ltd - COVID-19 Consent & Declaration of Truth

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I acknowledge the contagious nature of the Coronavirus/Covid-19 and that the WHO and many other Public Health authorities still recommend practicing social distancing. I further acknowledge that Exmoor Osteopathy Ltd has put in place preventative measures to reduce the spread of the Coronavirus/Covid-19. I further acknowledge that Exmoor Osteopathy Ltd cannot guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/Covid-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, clinic staff, and other clinic patients and their families. I voluntarily seek services provided by Exmoor Osteopathy Ltd and acknowledge that I am increasing my risk to exposure to the Coronavirus/Covid-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.

In consideration of my participation in the foregoing, the undersigned acknowledge and attest that: *

I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.

I have not travelled internationally within the last 14 days.

I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/Covid-19.

I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by local public health authorities.

I am following all WHO recommended guidelines as much as possible and limiting my exposure to the Coronavirus/Covid-19.

Required

I solemnly and sincerely declare that the information I have provided is true and correct and I make this solemn declaration conscientiously believing the same to be true. If any person should suffer as a result of the information being found to be untrue and false, then I am aware I can be prosecuted for making a false declaration.

Name *

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Signed Electronically *

Date Signed *

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