Any person who currently exhibits any of the key symptoms of Covid-19 (or lives with someone with symptoms) must not enter the practice until seven days after their high temperature has subsided.
The most common symptoms of coronavirus (COVID-19) are recent onset of any of the following:
1 - a new continuous cough
2 - a high temperature (37.8C or greater)
3 - a loss of, or change in, your normal sense of taste or smell (anosmia)
4 - unusual fatigue or shortness of breath
Please let me know if you are displaying any of these symptoms so we can reschedule your appointment
APPOINTMENTS & PRACTICE GUIDELINES
Only 1 patient will be allowed in the clinic at a time
A non-contact digital thermometer will be used to check your temperature on arrival to the clinic
You will need to clean your hands with the hand sanitiser provided on entry and exit of the clinic
Appointments will be strictly 45mins (75min if you are a new patient) allowing time to clean/disinfect the treatment area effectively for the next patient.
From 1 June 2020, each patient is required to read and complete this online form prior to attending their first appointment with me.
Practitioners/assistants will wear face-shields/masks and gloves
Patients will be provided with a type IIR medical disposable face mask
The treatment room and all communal areas of the building are cleaned thoroughly and high frequency contact areas will be disinfected regularly throughout the day.
Shared contact areas such as external and internal door handles, chairs, desks, treatment tables, surfaces in the toilet and payment terminals are cleaned daily and disinfected before each patient.
These items will be changed for every patient then washed and dried at 60°C before being used again:
• couch covers
• pillow cases
• face cushion covers
Date of birth
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.
I give my consent to receive treatment from this practitioner
After the appointment I will inform you if I develop Covid-19 symptoms or have a confirmed diagnosis of Covid-19 within 14 days of leaving your practice.
Date form completed
Never submit passwords through Google Forms.
This form was created inside of Glenn Delikan Acupuncture.