Crowthorne Body Health Covid19 Follow on appointments Consent form

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Covid19 relevant information and consent for follow on appointments

Email *

Name *

Address - including post code *

Mobile no *

I am registered with the NHS Track and Trace app *

Yes

I have had a Covid19 vaccination *

Yes

If you have answered Yes to the above question, when did you have your last dose?

YYYY

I have tested positive for Covid19 in the last 14 days *

Yes

If you have tested Positive for Covid19 in the last 14 days, please follow Government guidelines of self isolating. If you are self isolating, please contact your therapist to reschedule your appointment.

I have travelled back to the UK in the last 14 days *

Yes

To my knowledge, I have not been in contact with anyone with either Covd19 or Covid19 symptoms in the last 14 days. I am not experiencing any Covid19 symptoms either. *

True

False

Required

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

True

False

Required

Should anyone I have been in direct contact with over the past 14 days tests positive, 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 condition. I understand and agree to receive the treatment explained to me by the the therapist. I will keep the therapist up to date with any changes to my medical, mental and physical health. I accept that my details will be passed on if either I or the therapist develop Covid19 within 14 days of my last treatment.

Signature (type your name if you dont have an electronic signature) *

Date *

YYYY

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