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 which 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 informed about 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 the form and your consent.

Full Name (required)

Date Of Birth [DD-MM-YYYY] (required)

Phone / Mobile Number (required)

Address (required)

Address (required)

Post Code (required)

GP and Practice Name (required)

Your Email (required)

Preference Video ConsultationFace-To-Face Appointment

Confidential Checklist
Please Indicate If Any Of These COVID-19 High Risk Factors Apply To You:

Were You Required To Shield During This Pandemic?

Patients At Higher Risk (Clinically Extremely Vulnerable) - If you fall into the higher risk category you would have most likely received a letter from the NHS.

Weakened Immune SystemRecent Organ TransplantPregnant With A Heart ConditionSpleen ProblemsAdult With Down's SyndromeHaving DialysisStage 5 (long-term) Kidney DiseaseMedication Affecting The Immune System e.g. High Steroid Dose

Known Cancer Diagnosis And/Or Currently Having Active Treatment

Patients At Moderate Risk (Clinically Vulnerable) - If you fall into the moderate risk category you may not have received a letter from the NHS.

Age >70BMI >40Lung/Respiratory ConditionMedication That Affects The Immune System E.G. Low Steroid Dose

DiabetesChronic Kidney DiseaseLiver DiseaseHave a Condition That Affects The Brain Or Nerves e.g. Parkinson's, MND, MS or Cerebral PalsyRheumatoid ArthritisHigh Risk Of Getting InfectionsPregnant

This is not an exhaustive list. If there is anything further in your medical history that puts you at high risk of becoming seriously ill with Covid-19, please inform your physiotherapist.

There are other groups of patients that can become seriously ill with Covid-19
Age >60 (risk increases with age)Black, Asian Or Minority Ethnic Background

BY SUBMITTING THIS FORM YOU ARE CONSENTING TO THE FOLLOWING


You confirm that the information given is accurate and hereby give consent to receive assessment, treatment and advice with Edinburgh Sports + Spinal Physiotherapy (ES+SP) on this and any subsequent occasion. You understand that any information provided in this consent form or any other information discussed with your physiotherapist is confidential under applicable data protection laws, including the General Data Protection Regulation (GDPR).
ES+SP’s privacy policy can be accessed at www.physiotherapistsedinburgh.co.uk/privacy-notice.


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
3. Cancellation Policy: Please remember that cancellations and/or rescheduling have to be made 24 hours prior to your appointment. Unfortunately, failure to notify cancellation within this timeframe will result in a £25 fee. ​We understand that unavoidable circumstances arise and appointments have to be cancelled or rescheduled. Please call us on 0131 235 2354 during regular business hours to cancel or to reschedule your appointment.


Online Consultations (Calls or Video)
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. You are aware that mobile phones can only be as secure as any other phone call on that 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.


Face-To-Face Appointments
RISK OF CONTACT
• Transmission of COVID-19 is via contact, droplet or airborne mechanisms (aireborne transmission is usually via aerosol procedures, which are not carried out at Edinburgh Sports + Spinal 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 COVID-19
Despite all measures being taken there is always an elevated risk of contracting COVID-19 simply by entering the clinic due to:
• The frequency of visits of other patients
• The characteristics of COVID-19
• Close contact during face-to-face physiotherapy treatment



MEASURES TO MITIGATE THE ABOVE RISKS CONDUCTED BY EDINBURGH SPORTS + SPINAL PHYSIOTHERAPY
• Detailed risk assessment of working environment
• Taking all recommended infection prevention and control measures
• Maintaining 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 at the time of your appointment
• Complying with all government, Chartered Society of Physiotherapy, Physio First and the Health and Care Professionals Councils' guidance.


YOU MUST NOT ATTEND YOUR APPOINTMENT IF WITHIN THE LAST 14 DAYS YOU OR A MEMBER OF YOUR HOUSEHOLD:
• Develop any symptoms of COVID-19 (a new prolonged cough, high temperature, and/or change of taste or smell)
• Been in contact with anyone with COVID-19
• Become positively confirmed as having contracted COVID-19
• Been in contact with someone with Covid-19 symptoms
• Returned from an area or country that the government has imposed a self-isolation order
• If you are currently waiting the result of a Covid-19 test
Please notify Edinburgh Sports + Spinal Physiotherapy immediately by emailing info@physiotherapistsedinburgh.co.uk or preferably calling 0131 235 2354. 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.


You consent to Edinburgh Sports + Spinal Physiotherapy informing NHS Scotland Test & Protect with your personal details if there is a possibility that you have been exposed to Covid-19.


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. To find out more about this or to contact these companies regarding their own privacy policies, please ask your physiotherapist.
By consenting to this form, you also understand that certain communication is required as part of your ongoing treatment with us.




If there is anything in this form you wish to discuss or have explained in more detail, please do not hesitate to contact us on:
0131 235 2354


I have read or have had the above information 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 to face-to-face consultations. I understand that I may withdraw my consent at any time, without prejudice.





Edinburgh Sports + Spinal Physiotherapy is a trading name of ESS PHYSIOTHERAPY LIMITED - SC617097

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