Consent to Treatment Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Changes to Health and Consent to Treatment required

Email *

Name *

Mobile Number *

To my knowledge I am not currently experiencing any Covid19 symptoms. *

I have had a Covid19 vaccine

I have previously tested positive for Covid19

Neither of the above

Required

If you have received any Covid19 vaccinations or you have previously tested positive, when was your last vaccine dose or when did you test positive for Covid19?

YYYY

If you have tested positive for Covid19 in the last 5 days please follow Government Guidelines for self-isolating. If you are self-isolating please contact your therapist to reschedule your appointment.

My medical conditions have not changed since my last appointment with the therapist *

True

False

I confirm that the above information is accurate to the best of knowledge. I know of no reason why I should not receive treatment. I understand that the treatments undertaken by me are at my own risk and that the therapist may not be able to cure my condition. I understand and agree to receive the treatment explained to me by the therapist. I will keep the therapist up to date with any changes to my medical, mental and physical health.

Signature (type your name is you do not have an electronic signature) *

Date of signature *

YYYY

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Twickenham Body Health. Report Abuse

Forms