HOOLE ACUPUNCTURE CLINC
COVID-19 CONSENT FORM AND PATIENT QUESTIONNAIRE
Part 1 Covid-19 Consent Form: Please provide your name and address below:
Please provide a mobile contact number *
Current Date *
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Have you had fever in the last seven days (feeling hot to touch on your chest and back) *
Required
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) *
Required
Have you lost sensations of taste and smell? *
Required
Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has Coronavirus -type symptoms? *
Required
Do you or anyone that you live with fall into the clinically vulnerable or clinically extremely vulnerable categories as defined in the guidance below on the webpage? *
Consent for Treatment: 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 therefore give my consent to treatment from the practitioner listed below. *
Name *
Signature (You will be asked to sign at the clinic)
In compliance with the Data Protection Act framework we will not store your data digitally. The form generated will be printed off and stored in hard copy for your signature and the digital message deleted. The Hoole Acupuncture Clinic does not store a digital database of patient records and only stores hard copies securely with the agreement of patients.
Clear selection
Date (Please Date at Clinic on your Appointment)
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If you are signing on behalf of a patient or the patient is a minor please state your relationship with the patient
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