Covid-19 Consent - Heather Adams

Have you had a fever in the last 10 days? *

Feeling hot to the touch on your chest and/or back.

Do you now, or have you recently had, a persistent dry cough? *

Coughing a lot for more than an hour, 3 or more coughing episodes in 24 hours or worsening of a pre-existing cough.

Have you lost sensations of taste and smell? *

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

Have you been told to stay at home, self-isolate, or self-quarantine? *

Do you, or anyone that you live with, fall into the “clinically vulnerable” or “clinically extremely vulnerable” categories? *

NHS Test & Trace consent (please read full text below) *

I consent

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. In the eventuality that the practitioner gets symptoms of Covid-19 within 48 hours of having close contact during your appointment and later test positive, the practicioner is obligated under law to provide your name, phone number or email address, and the date & time of your visit to the NHS Test & Trace service.

General Data Protection Regulation consent (please read full text below) *

I consent

I understand that my data will be held in accordance with the law an d the Privacy Policy of the practitioner's website. Data is held according to the British Acupuncture Guidelines and will not be shared with anyone else without consent. Please be aware that if you don’t attend, cancel, or re-schedule your appointment with less than 24 hours notice I may charge a fee.

Sign by typing your name *

I give my consent to receive treatment from this practitioner. (If you are signing on behalf of the patient, please state your relationship.)