Information & Consent Form
Risk of Coronavirus (COVID-19) Transmission at Barnstaple & Holsworthy Chiropractic Clinics
We are asking all patients to read the below very carefully and sign prior to their appointment.
We thank you in advance for your understanding and co-operation.
The Government published a Statutory Instrument on 26th March 2020, no. 350 ‘The Health Protection (Coronavirus, Restrictions) (England) Regulations 2020’ confirming that it is lawful for a chiropractic practice to remain open. It further defines those people who are recognised as vulnerable for the purposes of this document.
We have conducted a thorough risk assessment to ensure adequate levels of safety are implemented and maintained. We are following the most up-to-date Government and Public Health England guidance and have put in place stringent hygiene, sanitation and infection control protocols to protect our patients and team members. Despite these precautions, there is a risk of transmission of the Coronavirus (COVID-19) and it is important that you understand the risk. We have provided the information below to help you decide if you wish to continue with your care at the clinic and remind you that you are under no obligation to do so.
Before arriving at Barnstaple/Holsworthy Chiropractic Clinic for any appointment patients need to inform the clinic before arrival:
· Whether symptoms of Covid 19 are present. These include cold or flu like symptoms for example, fever, cough, sore throat, respiratory illness, difficulty breathing, loss of taste or smell.
If they are self-isolating;
If anyone in their household has symptoms or is self-isolating;
Or they have been in contact with anyone with COVID-19 symptoms.
We enforce a strict policy that anyone with any COVID-19 symptoms must stay away from the clinic.
Also see ‘Eligibility for Care’ guidelines below.
On Arrival at the Clinic:
· A second assessment is conducted at the Clinic, including a temperature check.
· A strict cleaning, sanitation and infection control protocol is adhered to – please ask if you would like to see this document.
· All team members at the clinics adhere to the social distancing guidelines issued by the Government;
· The layout of the clinic and timing of appointments have been adapted to maintain social distancing;
· Clinical team members will be wearing Personal Protective Equipment (PPE) for everyone's protection
· Patients will be wearing masks.
· Our clinics are committed to ensuring that every measure is in place to minimise the risk of exposure to COVID-19, we cannot guarantee there is no risk to you as a result of attending the clinic.
People can catch COVID-19 from others who have the virus. The disease can spread from person to person through small droplets from the nose or mouth which are spread when a person with COVID-19 coughs or exhales. These droplets land on objects and surfaces around the person. Other people then catch COVID-19 by touching these objects or surfaces, then touching their eyes, nose or mouth. People can also catch COVID-19 if they breathe in droplets from a person with COVID-19 who coughs out or exhales droplets.
The risk of catching COVID-19 from someone with no symptoms at all is very low. However, many people with COVID-19 experience only mild symptoms. This is particularly true at the early stages of the disease. It is therefore possible to catch COVID-19 from someone who has, for example, just a mild cough and does not feel ill (World Health Organisation).
Eligibility for Care
In addition to those with COVID-19 symptoms, self-isolating or living with someone with symptoms/ self-isolating, we will assess the need for face to face contact with patients from the “at risk” groups defined below:
- Over 70
- Have a long-term health condition/ underlying Medical Conditions as listed below: -
· - Chronic (long-term) respiratory diseases, such as asthma, chronic obstructive pulmonary disease, emphysema or bronchitis
· - Chronic heart disease, such as heart failure
· - Chronic kidney disease
· - Chronic liver disease, such as hepatitis
· - Chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis, a learning disability or cerebral palsy
· - Diabetes
· -Problems with the spleen, such as sickle cell disease or removal of the spleen
· -A weakened immune system as the result of conditions such as HIV and AIDS, or medicines such as steroid tablets or chemotherapy.
· -Being seriously overweight, with a body mass index of 40 or above.
Consent to receive care at
Barnstaple and Holsworthy Chiropractic Clinics
Please check all of the boxes below before submitting your form: *
I have had the opportunity to ask all the questions I wish to, and all my questions have been answered to my satisfaction.
Should I have further questions that arise between submitting this form and up to and including when my appointment starts, I will raise these with the clinical team member before any treatment takes place.
I have read, agreed to and understood the statements above relating to Coronavirus (COVID-19) risk and consent to receive care at Barnstaple/Holsworthy Chiropractic Clinic.
I understand and agree that I will need to give separate verbal consent regarding my chiropractic care.