Covid19 Follow up Appointment Consent Form
Consent form and update of any Covid19 pertinent information 24 hours prior to your appointment
Sign in to Google to save your progress. Learn more
Email *
Name *
Address - including post code *
Mobile Number *
I am registered with NHS Test and Trace app *
I have had a Covid-19 vaccination? *
If you answered 1, 2 or more to the above question - when did you have your last dose?
MM
/
DD
/
YYYY
I am experiencing Covid19 symptoms. (If yes, please self isolate according to Government guidelines. Your appointment will need to be re-booked when you have a negative Covid19 test.) *
I have travelled back to the UK in the last 14 days *
Should I be advised to self-isolate due to Covid19 or I test positive for Covid19 over the next 10 days I will inform you. I confirm that the above information is accurate to the best of my knowledge and that all necessary precautions are in place to prevent the spread of Covid19 and that I am happy to undergo treatment. I know no reason why I should not receive treatment. I understand that treatments undertaken by me are at my own risk and that the therapist may not be able to cure my complaint. I understand and agree to receive the treatment explained to me by the therapist. I will keep my therapist up to date with any changes to my medical, mental or physical health. I accept my details are to be passed on if either I or my therapist develop Covid-19.
Electronic signature *
Date completed *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Twickenham Body Health. Report Abuse