Covid19 Informed Consent

COVID-19 INFORMED CONSENT

Please find below Symantha’s Talking Therapy’s safety statement with respect to Covid-19. You will be requested to complete this the day before each and every therapy session that you are booked in for. I ask that you fill out this form truthfully and please notify the practice of any changes at any time to the statements in the form.

Please read my Covid-19 safety measures before completing the form below.

Name *

First

Last

Contact Number *

Contact Email *

First Line of address: *

House name/ number and street

Postcode *

I have not shown any symptoms of Covid-19 in the past 14 days. (NHS and Gov.UK define the main symptoms as high temperature, new, continuous cough, loss or change to your sense of smell or taste). *

I agree with the statement above

I have not knowingly been in contact with anyone who has tested positive for Covid-19 or shown any of the above symptoms in the past 14 days. *

I agree with the statement above

I have worn a protective mask where it is law to do so. *

I agree with the statement above

I understand Symantha's Talking Therapy's safety procedures to prevent the spread of Covid-19 and am happy to follow these procedures. *

I agree with the statement above

I agree to inform the practice immediately if I develop Covid-19 symptoms within a two week period of being in the therapy room, or if I learn that I have been in direct contact with someone who has later tested positive for Covid-19 within the same two week period or has travelled in the last 14 days to and/or from a Covid-19 risk area. *

I agree with the statement above

I have not previously been requested to self-shield having been identified as being clinically extremely vulnerable due to underlying health conditions. *

I agree with the statement above

I agree that my data provided on this form can be used to contact me in the unlikely event that my therapist later tests positive for Covid-19, within 14 days following our session. *

I agree with the statement above

I agree to all Terms and Conditions *

I agree

If you have been unable to agree with all of the statements above please contact the practice to cancel or rearrange your appointment.

Contact me via connect@symanthas.com or call me on 07918 396 814 leaving a message if I am unavailable.

Alternatively complete the contact form via the link below.