- Poole 01202733355
- Blandford 01258455214
Covid-19 Consent Form
Back in Form Chiropractic Clinics operate with very strict hygiene and sanitation protocols in place, to protect ourselves and our patients. Despite these precautions, there is an inherent risk of human-to-human transmission of the Coronavirus (COVID-19). Symptomatic people should NOT visit the practice at this time.
Whilst Back in Form Chiropractic Clinics are taking every further precaution to limit your risk of exposure, we cannot guarantee that there is no risk to you as a result of attending the clinic and/or receiving treatment.
How does Coronavirus spread?
This virus appears to spread easily and it is thought this is mainly from person-to-person, through people who are in close contact with one another or through respiratory droplets produced when an infected person talks, coughs or sneezes. It can also be contracted from surface contact. It is most likely that people contract the virus and can spread this easily for some time, before they show symptoms. The patients identified as being at increased risk of severe illness from COVID-19 are;-
High risk of developing complications from coronavirus (COVID-19) infection.
Solid organ transplant recipients.
People with specific cancers:
People with cancer who are undergoing active chemotherapy
People with lung cancer who are undergoing radical radiotherapy
People with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment
People having immunotherapy or other continuing antibody treatments for cancer
People having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
People who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs
People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe chronic obstructive pulmonary (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.
Moderate risk of developing complications from coronavirus (COVID-19) are:
Aged 70 or older (regardless of medical conditions)
Under 70 with an underlying health condition listed below (for adults this is usually anyone instructed to get a flu jab as an adult each year on medical grounds):
Chronic (long-term) respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), 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 (MS) or cerebral palsy
Diabetes
Those with a weakened immune system caused by a medical condition or medications such as steroid tablets or chemotherapy
Being seriously overweight (a BMI of 40 or above)
Patients are low risk if they are not in the moderate or high-risk groups
We ask these groups to consider the risks to yourself and others, based on the government advice, before commencing any treatment. Please only consider chiropractic care if you are in acute pain and require treatment.
Consent to receive care
By signing below, I confirm that I have read, agreed and understood the statements above and consent to receive care at Back in Form Chiropractic Clinics
Patient’s Name (print) ____________________________________________
Signed: ______________________________________ Date: __
Covid-19 consent Form