Consent form

Name

Address

Date of birth

Phone

Any private health insurance?

Yes

Private health insurance details, if using (e.g. Bupa, Aviva, AXA Health etc. Do not provide medico-legal claim details or referrals through a solicitor)

Reason for appointment

COVID-19 Consent Form

I knowingly and willingly consent to have face to face treatment

I understand the COVID -19 virus may have a long incubation period, during which carriers of the virus may not show symptoms and still be highly contagious

I confirm that neither myself or any member of my household, have had any of the following symptoms of COVID-19 within the last 10 days; sore throat, cough, headache, runny nose, sneezing or fever (https://joinzoe.com/learn/omicron-symptoms)

I have not been told to isolate in the last 10 days by NHS Test and Trace. For the latest guidelines on isolation, visit https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-and-treatment/when-to-self-isolate-and-what-to-do/

I affirm that I, as well as all household members, have adhered to any travel restrictions for travelling in or out of the country as per government guidelines

I understand that this business and any member of the Top To Toe Physiotherapy team cannot be held liable for any exposure to the virus or and other contagion caused by misinformation on this form or the health history provided by each client

By submitting this form, I agree to each of the above statements and release any Top To Toe Physiotherapy team member from any and all liability for the unintentional exposure or harm due to COVID-19.

All of the members of the Top To Toe Physiotherapy team agree they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to fight the spread of COVID-19 and other communicable conditions more thoroughly.

In the unlikely event that one of our therapists test positive for COVID-19 following your appointment, we will need to provide patient details to UK Health Security Agency and NHS Test and Trace. By submitting this form, you consent for your details to be passed on to UK Health Security Agency and NHS Test and Trace.

Consent for treatment and to process your details

By submitting this form, you consent to be treated by Top to Toe Physiotherapy and understand that certain communications will be required as part of that treatment either through phone, SMS or email. Communications include but are not limited to appointment confirmations and reminders, request for further details relating to your treatment and information and services relating to the clinic.

You are free to opt out at anytime by emailing info@toptoephysiotherapy.co.uk

Consent form

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