Patient Information and Consent Form
Risk Control of Coronavirus (COVID-19) Transmission at The Back Room Chiropractic (TBR)
*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. There have been several further documents issued by Public Health England providing guidance for health care providers which we have stringently adhered to throughout.
TBR has conducted a thorough risk assessment to ensure adequate levels of safety at this clinic are implemented and maintained and we are following the most up-to-date version of guidance from Public Health England: COVID-19: Guidance for maintaining services within health and care settings Infection prevention and control recommendations Version 1.2, issued on June 1st 2021.
Despite all the stringent precautions we have implemented, 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 TBR and remind you that you are under no obligation to do so.
Precautions that TBR has in place:
- All patients contacting us for an appointment are triaged via a questionnaire to see 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 short 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 TBR adhere to the social distancing guidance issued by the Government.
- The layout of the practice has been adapted to maintain social distancing where possible.
- Chiropractors and Clinical Staff will be wearing Personal Protective Equipment for your protection.
- Covid Vaccination: Some staff members as well as some patients attending this practice may not be vaccinated due to eligibility, medical contraindications / exemptions or personal preference. To keep everyone safe, strict infection prevention control measures are in place and all of our staff will be in the appropriate level of PPE. LFD (Lateral Flow) testing is also carried out on all staff at regular intervals. If you have any concerns, please us know.
TBR 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.
Consent to receive care at TBR
- 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 TBR.
- I understand and agree that I will need to give separate consent regarding my chiropractic care.