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:

  • All patients contacting us for an appointment are triaged by a trained healthcare professional (usually a chiropractor) over the telephone to establish whether symptoms are present, 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.
  • A second triage 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 Backroom Chiropractic adhere to the social distancing guidance issued by the Government.
  • The layout of the practice has been adapted to maintain social distancing.
  • Patients waiting are restricted to one at any time and a 2-metre distance will be enforced between patients and non-clinical team members.
  • Chiropractors and Clinical Staff will be wearing Personal Protective Equipment for your protection.

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:

  1. Solid organ transplant recipients.
  2. People with specific cancers:
    • People with cancer who are undergoing active chemotherapy
    • People with lung cancer who are undergoing radical radiotherapy
    • People with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment
    • People having immunotherapy or other continuing antibody treatments for cancer
    • People having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
    • People who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs
  1. People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe chronic obstructive pulmonary (COPD).
  2. People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as Severe combined immunodeficiency (SCID), homozygous sickle cell).
  3. People on immunosuppression therapies sufficient to significantly increase risk of infection.
  4. Women who are pregnant with significant heart disease, congenital or acquired.

 

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.

– Pregnant

– 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.
  • 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 The Back Room Chiropractic

  • I have answered all questions (triage) relating to my potential exposure to Coronavirus (COVID-19) truthfully.
  • I understand that there is a potential risk of transmission of Coronavirus (COVID-19) as a result of attending the clinic and/or receiving treatment.
  • I have had the opportunity to ask all the questions I wish to, and all my questions have been answered to my satisfaction.
  • I have read, agreed to and understood the statements above relating to Coronavirus (COVID-19) risk and consent to receive care at The Back Room Chiropractic
  • I understand and agree that I will need to give separate consent regarding my chiropractic care.

 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.