Please note the form below must only be completed where you have recently commenced a new course of treatment and have already completed the initial Covid-19 Triage and Consent Form prior to your initial consultation.
Due to the current COVID-19 pandemic the safety of everyone attending the clinic is of paramount importance. As part of new safety measures anyone attending the clinic is now required to complete an additional Triage and Consent Form. This ensures patients understand the nature of the treatment they are booked in for, and allows us to identify any potential Covid-19 risks. Access to face-to-face treatment cannot proceed without a completed form. Whilst this can be done within the timeframe provided for your treatment it would be really helpful if this could be completed online prior to your arrival. Please note our website is secured and verified with a digital certificate of security seen at the bottom of each page.
We really appreciate and would like to thank you for your understanding and patience whilst we endeavour to keep all our patients, staff and their families safe from the Coronavirus. Should there be any problems completing the form please contact the clinic on 01943 850723 or by email at firstname.lastname@example.org.
PLEASE COMPLETE ALL SECTIONS.
If the patient is under 16 years of age, this form should be completed by a parent/guardian.
NO DETAILS ARE STORED ON THIS WEBSITE. DETAILS SUBMITTED ARE REQUIRED FOR THE PROVISION OF FACE TO FACE TREATMENTS ONLY AND WILL NOT BE USED FOR ANY MARKETING PURPOSES NOR RELEASED TO ANY THIRD PARTIES.