Covid-19 Consent Form

Screening and treatment consent form:

Please fill in this form below within 24hrs of your scheduled appointment. It’s a necessary requirement before each treatment.

    Your Name (required)

    Your Email (required)

    Your Phone (required)

    Treatment date (required)

    1. Have you or anyone in your household had high temperature, sore throat, cough, loss of taste/smell in the last 2 weeks?

    YesNo

    2. Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has coronavirus-type symptoms?

    YesNo

    3. Do you or anyone that you live with fall into the ‘clinically vulnerable’ or ‘clinically extremely vulnerable’ categories as defined below?

    YesNo

    4. Have you been told to stay home, self-isolate or self-quarantine?

    YesNo

    5. I understand that the therapist/instructor will wipe down all surfaces before and after my attendance and they will be wearing PPE as set out by health authorities.

    YesNo

    6. I understand that my details may be passed on to NHS Test and Trace, if necessary.

    YesNo

    7. Have you recently travelled abroad or to any of current COVID hot spots?

    YesNo

    8. I understand that, because my treatment may involve touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including Covid-19.

    I give my consent to receive tuina treatment from Piotr Radowicz.

    YesNo

    Comments or more details:

    Clinically vulnerable people

    People in this category of risk include:

    1. Anyone aged 70 and older (regardless of medical conditions.
    2. Anyone under 70 with an underlying health condition (that is, anyone instructed to get a flu jab as an adult each year on medical grounds) – such as:
      • chronic (long-term) mild to moderate respiratory diseases, such as asthma, chronic
        obstructive pulmonary disease (COPD), 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 (MS), a learning disability or cerebral palsy
      • diabetes
      • a weakened immune system as the result of conditions such as HIV and AIDS, or medicines (such as steroid tablets )
      • being seriously overweight (a body mass index (BMI) of 40 or above)
      • pregnant women

    Clinically extremely vulnerable people

    People in this category of risk include:

      1. Solid organ transplant recipients.
      2. People with specific cancers:
        a) people with cancer who are undergoing active chemotherapy
        b) people with lung cancer who are undergoing radical radiotherapy
        c) people with cancers of the blood or bone marrow such as leukaemia, lymphoma or
        myeloma who are at any stage of treatment
        d) people having immunotherapy or other continuing antibody treatments for cancer
        e) people having other targeted cancer treatments which can affect the immune system,
        such as protein kinase inhibitors or PARP inhibitors
        f) people who have had bone marrow or stem cell transplants in the last 6 months, or
        who are still taking immunosuppression drugs
      3. People with severe respiratory conditions including all cystic fibrosis, severe asthma and
        severe chronic obstructive pulmonary disease (COPD).
      4. People with rare diseases that significantly increase the risk of infections (such as severe
        combined immunodeficiency (SCID), homozygous sickle cell).
      5.  People on immunosuppression therapies sufficient to significantly increase risk of
        infection.
      6. Women who are pregnant with significant heart disease, congenital or acquired.
      7. Other people have also been classed as clinically extremely vulnerable, based on clinical
        judgement and an assessment of their needs. GPs and hospital clinicians have been provided with guidance to support these decisions.

     

    More information about who has been classed as clinically extremely vulnerable is available on the NHS Digital website.

    Please read about the special measures in place and how to receive the treatment:

    Covid-19 Safe Clinic info
    Data443 Privacy Safe
     

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