Information & Consent Form

Risk of Coronavirus (COVID-19) Transmission at

We are asking all patients to read the follwoing information carefully and electronically submit the below form to confirm their understanding and agreement before attending the clinic for their appointment.

We thank you in advance for your understanding and co-operation.

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 and osteopathy practice to remain open. It further defines those people who are recognised as vulnerable for the purposes of this document.

Aligned Health has conducted a thorough risk assessment to ensure adequate levels of safety are implemented and maintained. We are following the most up-to-date Government and Public Health England guidance and have put in place stringent patient triage, hygiene, sanitation and infection control protocols to protect our patients and team members. 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 Aligned Health and remind you that you are under no obligation to do so.

Precautions that Aligned Health is following:

All patients contacting us for an appointment are sent this form and confirm that they understand the following:

We enforce a strict policy that anyone with any COVID-19 symptoms must stay away from the clinic.
A triage is conducted at the Clinic, including a temperature check.
A strict cleaning, sanitation and infection control protocol is adhered to.
All team members at Aligned Health adhere to the social distancing guidelines issued by the Government.
The layout of the clinic and timing of appointments have been adapted to maintain social distancing.
Clinical team members will be wearing Personal Protective Equipment (PPE) for everyone’s protection.
Aligned Health 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.

Before we can offer physical face to face appointments to patients from the vulnerable “High Risk” groups defined by the NHS; see below, we will need a referral from your GP or person in charge of your care:

Solid organ transplant recipients.
People with cancer or has received cancer treatment in the last 6 months.
People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe chronic obstructive pulmonary Disease (COPD).
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).
People on immunosuppression therapies sufficient to significantly increase risk of infection.
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 are 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:

1. 1. Chronic (long-term) respiratory diseases, such as asthma, chronic obstructive pulmonary disease, emphysema or bronchitis.
  2. Chronic heart disease, such as heart failure.
  3. Chronic kidney disease.
  4. Chronic liver disease, such as hepatitis.
  5. Chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis, a learning disability or cerebral palsy.
  6. Diabetes.
  7. Problems with the spleen, such as sickle cell disease or removal of the spleen.
  8. A weakened immune system as the result of conditions such as HIV and AIDS, or medicines such as steroid tablets or chemotherapy.
  9. Being seriously overweight, with a body mass index of 40 or above.

Following an update from the Government patients are advised to wear face coverings while attending clinic but that it is not mandatory.

Consent to receive care at Aligned Health Clinic

Please check ALL of the boxes and answer all of the questions below before submitting your form.
This information will be used to update your practitioner before you attend the clinic and therefore
ensure the time in the clinic is used more efficiently.

I have read all the information above (triage) relating to my potential exposure to Coronavirus (COVID-19)

Yes

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.

Yes

Should I have any questions that arise between submitting this form and up to and including when my appointment starts, I will raise these with the Clinical team member before any treatment takes place.

Yes

I understand that from 24 July 2020 wearing a face covering is recommended when attending the clinic

Yes

I have read, agreed to and understood the statements above relating to Coronavirus (COVID-19) risk and consent to receive care at Aligned Health

Yes

During the closure have you been:

If working from home have you been working from a usual desk setup or not?

Have you been more or less sedentary than normal?

If less, what new activities have you been doing?

For how long, and how frequently have you been doing this exercise?

How well do you feel you have dealt with the stress of COVID-19 on a scale of 1-10 with 1 being not dealing well at all, and 10 being I have dealt very well and felt no stress.

Has the quality of your diet improved or declined?

Approximately how many units of alcohol have you consumed during an average week? (1.5 Units = small glass of red/white/rosé wine)

Have you had symptoms of COVID-19?

If answered yes to the previous question, have you been tested positive for COVID-19?

Since your last adjustment, do you feel the progress you had made so far has continued to improve, maintained or relapsed to a degree?

Do you have any new symptoms that were not present before the closure?

Have you had any new injuries such as trips, falls, concussions, broken bones etc?

Have you continued to carry out the exercises prescribed by your practitioner to the exact recommendation?

Are there any other health and lifestyle concerns that we can help support you with?

Signed