Covid-19 Treatment Consent

Please read, sign and submit this form prior to your appointment taking place. This will avoid the need for you to sign it at reception. You only need to do this once.

Based on what is currently known about COVID-19, the spread is thought to occur mostly from person-to-person via respiratory droplets among close contacts. Close contact can occur from being within approximately 6 feet of someone with COVID-19 for a prolonged period of time.

I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious.

I understand that if I visit or live with someone in a high risk/ vulnerable category, then I should avoid close contact with others.

I understand that due to the unknowns of this virus, the number of other patients that have been in the practice and the nature of the treatments performed here, that I may have an increased risk of contracting the virus by being in the practice and receiving treatment here. 

Known symptoms representative of COVID-19, according to the NHS

  • high temperature – this means you feel hot to touch on your chest or back (you do not need to measure your temperature)
  • new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual)
  • loss or change to your sense of smell or taste – this means you’ve noticed you cannot smell or taste anything, or things smell or taste different to normal

    Check the relevent boxes to confirm that:

    Problem with the form?

    Give us a call on 0191 398 0000 and one of the team will try to assist.