Consent Form

Patient Consent Form

Our priority is the safety of our patients and staff in order to reopen the clinic for face to face services. We have had to implement a number of changes we would like to make you aware of including gaining your consent via this electronic form. It is also our professional responsibility to ensure you are fully aware of the potential risks of infection of Covid 19 and attending a face to face consultation.
Please fill out the required information and read all the information carefully prior to submitting your consent.

Confidential Check List

Please indicate if any of these Covid-19 risk factors apply to you

Acceptance

I have read or have had the information on this page read and explained to me. I have also had the opportunity to ask questions about its content and the risks of COVID 19 infection with regards face to face consultations. I understand that I may withdraw my consent at any time, without prejudice.

PLEASE READ BELOW

Payment and Medical Insurance (if applicable)

You agree to take full responsibility for:

  1. The payment of all treatment costs if self paying
  2. Ensuring medical insurance is pre-authorised and paid in full including excesses
 

Remote Consultation Calls

Whatsapp  video consultations are securely encrypted, however, it is your responsibility to ensure that you have adequate anti-spyware and anti-virus protection on the devices you use.  Your are aware that mobile phones can only be as secure as any phone calls are on the mobile network.  The consultation will not be digitally recorded, however, clinical outcomes will be recorded and stored on your patient records.  You are aware that remote consultations are treated as any other consultation in which sensitive or confidential information is always safeguarded

Communicating (email, phone, post) with you regarding your physiotherapy care

To ensure that we provide you with efficient physiotherapy care, we use carefully selected and secure IT programmes, exercise prescription software, diary system and an external admin support company to input your data.  These systems/companies do not share your data with any other third parties.

By consenting to this form, you also understand that certain communication is required as part of your on going treatment with us.  You are also aware that your details my be passed to government contact and trace teams if it is deemed necessary.

COVID 19

  • Transmission of COVID 19 is via contact, droplet or airborne mechanism (airborne transmission is usually via aerosol procedures, which are not carried out at Omagh Physiotherapy)
  • Consenting to face to face consultation which may involve manual therapy, puts you within the current 2 metre government social distancing guidelines
  • Being within social distancing guidelines carries a greater risk of potential infection of COVID19
 

Despite all measures being taken there is always an elevated risk of contractine COVID 19 simply by entering the clinic due to:

  • The frequency of visits of other patients
  • The charactersitics of COVID 19
  • Close contact during face to face physiotherapy treatment
 

Measures to mitigate the above risks conducted by Omagh Physiotherapy

  • Detailed risk assessment of working environment
  • Taking all recommended infection prevention and control measures
  • Maintaing the highest hygiene standards
  • Using advised PPE appropriate for each individual consultation, which will consist of sterile gloves, apron and face mask
  • Providing patients with a new mask if required, at the time of appointment
  • Complying with all government, CSP and HCPC guidelines
 

YOU MUST NOT ATTEND YOUR APPOINTMENT IF YOU:

  • Develop any symptoms of COVID 19 ( a new prolonged cough, high temperature, and/or a change of taste or smell)
  • Been in contact with anyone with COVID 19
  • Become positively confirmed as having contacted COVID 19
  •  

Please notify Omagh Physiotherapy and Sport Injury clinic immediately by email : omaghphysiotherapy1@btconnect.com or call 0288 224 9444. There will not be a late cancellation charge if you are unable to attend your appointment due to COVID 19 symptoms or if you are required to self-isolate.

 If there is anything in this form you wish to discuss or have explained in more details, please do not hesitate to contact us on: 028 8224 9444