Patient Information and Consent Form
Please read fully as you will be asked to sign this form on each visit to the clinic.
Risk of Coronavirus (COVID-19) Transmission at The Back Room Chiropractic Ltd
*This Form is in addition to consent form for chiropractic examination and treatment*
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 document.
The Backroom has conducted a thorough risk assessment to ensure adequate levels of safety at this clinic are implemented and maintained. We are following the most up-to-date Government and Public Health England guidance and put in place stringent patient triage, hygiene, sanitation and infection control protocols to protect our patients and staff/ team members (delete as necessary). 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 Back Room and remind you that you are under no obligation to do so.
Precautions that The Back Room Chiropractic has in place:
The Backroom Chiropractic is 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
We are unable to offer face-to-face appointments to the following people: If you self-isolating – until your isolation period is over and you have no symptoms; you have COVID-19 symptoms (whether diagnosed by test or not); if you are living with someone with COVID-19 symptoms (whether diagnosed by test or not); you have been in contact with anyone with suspected or confirmed COVID-19 and have been asked to self-isolate for 14 days by the Contact Tracing Service.
We are currently unable to accept patients from the vulnerable “High Risk” groups defined by the NHS below:
If you are in the “Moderate Risk” group as defined by the NHS below, we may be able to offer you a face to face appointment if it is deemed safe to do so.
– Over 70
– Have a long-term health condition/ Underlying Medical Conditions as listed below:
Consent to receive care at The Back Room Chiropractic
For patients in the “Moderate Risk” groups only:
I understand that my condition puts me in the ‘moderate risk’ group as defined by the NHS and acknowledge that I have been given a full explanation of any additional risk.