Information & Consent Form

Risk of Coronavirus (COVID-19) Transmission at The Health & Vitality Centre

We are asking all our guests to read the below 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 practice to remain open. It further defines those people who are recognised as vulnerable for the purposes of this document.

The Health & Vitality Centre 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 feel comfortable attending The Health & Vitality Centre for your care at this time and remind you that you are under no obligation to do so.

Precautions that The Health & Vitality Centre is following:

  •  All patients contacting us for an appointment are triaged by your chiropractor to establish:
    - 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 or living with family that have
    symptoms must stay away from the clinic.
  •  A second 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 The Health & Vitality Centre 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
  •  The Health & Vitality Centre 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 Car

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:
1.     Solid organ transplant recipients.
2.     People with cancer or has received cancer treatment in the last 6 months.
3.     People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe chronic
obstructive pulmonary Disease (COPD).
4.     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).
5.     People on immunosuppression therapies sufficient to significantly increase risk of infection.
6.     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 may 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:
·      Chronic (long-term) respiratory diseases, such as asthma, chronic obstructive pulmonary disease, 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, a
learning disability or cerebral palsy.
·      Diabetes.
·      Problems with the spleen, such as sickle cell disease or removal of the spleen.
·      A weakened immune system as the result of conditions such as HIV and AIDS, or medicines such as steroid
tablets or chemotherapy.
·      Being seriously overweight, with a body mass index of 40 or above.

Consent to receive care at The Health & Vitality Centre

  • Please check all of the boxes below before submitting your form:
  • Review Form following lockdown

  • Please describe here where your worst area of pain is on the image above
  • You will be reassessed by me when you come in but how do you feel that your body has coped over this time? Do you feel you need some extra chiropractic massage and care from us as a result of lockdown?
  • This field is for validation purposes and should be left unchanged.