COVID-19 informed consent and screening form

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RW Sports Injury Clinic COVID-19 Screening form

Informed consent

If this is my (patient’s) first session, I will complete a general online informed consent and screening form. This online form is to collect personal and medical details and reduce face to face contact (https://www.rwsportsinjury.com/legal). Before each treatment, the therapist will complete a COVID-19 triage over the phone or vis telehealth platform to see if other health treatments are needed and face to face treatment is safe. I will complete an online COVID-19 informed consent and screening form (the present form from https://www.rwsportsinjury.com/COVID-19). If the COVID-19 screening form is not completed before a treatment session, I will have to complete it before the session. This additional administrative task may reduce my treatment segment of the session. There will be no waiting room facilities. I understand that the therapist will test my temperature before every treatment. The therapist has completed the COVID-19 Infection Prevention and Control certificate by the Health Service Executive (HSE). The therapist will wear personal protective equipment (PPE) mask for the full extent of the session. All surfaces which I may touch have been disinfected before the treatment session. All surfaces (chair, bed, pillows and exercise equipment), which I will come in to contact with will be disinfected at the beginning of the treatment session. Treatment sessions will consist of 10 minutes of subjective history, 5 minutes of objective history, 15 minutes of treatment. The therapist has the right to refuse treatment and recommend a virtual session or refer to other health professionals.

Email *

Have you or have you had a fever (>38°C) in the past 14 days? *

Yes

Have you or have you had a cough in the past 14 days? *

Yes

Have you or have you had a shortness of breath in the past 14 days? *

Yes

Have you or have you had breathing difficulties in the past 14 days? *

Yes

Have you or have you had a sore throat in the past 14 days? *

Yes

Have you or have you had a runny or blocked nose in the past 14 days? *

Yes

Have you or have you had any wheezing in the past 14 days? *

Yes

Have you or have you had a loss of sense of smell or taste in the past 14 days? *

Yes

Are you or have you self-isolated in the past 14 days? *

Yes

Have you been in contact with some who has, or you think may have or had COVID-19 in the past 14days? *

Yes

A copy of your responses will be emailed to the address you provided.

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