Risk of Coronavirus (COVID-19) Transmission at Lido Chiropractic Clinic

Please read this form, discuss with your chiropractor if necessary and sign where indicated.

*This Form is in addition to consent form for chiropractic examination and treatment*

The Government published a Statutory Instrument on 26th March 2020, no. 350 ‘The Health
Protection (Coronavirus, Restrictions) (England) Regulations 2020’ confirming that it is lawful for a
chiropractic practice to remain open. It further defines those people who are classed as ‘vulnerable’.

In accordance with up-to-date Government and Public Health England guidance Lido Chiropractic
Clinic has taken precautions to protect our patients and team members. These include rigorous
sanitization procedures. We also request that any symptomatic patients follow NHS guidance on
self-isolation and refrain from visiting the practice at this time. Despite this, there is a risk of
transmission of the Coronavirus (COVID-19) and it is important that you are aware of the risk.

PRECAUTIONS THAT LIDO CHIROPRACTIC CLINIC HAS IN PLACE:

• All patients contacting us for an appointment are triaged by a member of our team over the
  telephone to establish their status (asymptomatic / symptomatic / self-isolating / living with
  someone symptomatic or self-isolating / have been in contact with anyone symptomatic).
• Only people in the asymptomatic category can attend the practice.
• A second triage is conducted at the practice by a team member.
• A strict cleaning, sanitation and infection control protocol is adhered to.
• All team members at Lido Chiropractic Clinic follow government social distancing
  guidance where possible.
• Practice layout has been adapted to maintain social distancing between patients and all team
  members where possible.

COVID-19 SYMPTOMS

The symptoms are a new continuous cough and/or fever which may be accompanied by one or more
of the following:

• headaches
• tiredness
• muscle ache
• respiratory symptoms besides cough such as a sore throat, blocked or runny nose
• gastro-intestinal symptoms can also be a feature of COVID 19 and these are more common in
children than adults
• loss of smell and taste (in some cases this may be the only symptom present)
If you are experiencing any of the accompanying symptoms listed above, regardless of having a new
continuous cough and / or fever, and are concerned that you may have coronavirus you should call
the helpline on +44 (0) 1534 445566.

ELIGIBILITY FOR CARE

In addition to those with COVID-19 symptoms, self-isolating, living with someone with symptoms/
self-isolating, or have been in contact with anyone with or suspected to have COVID-19, we are
currently not accepting patients from the ‘vulnerable’ and ‘extremely vulnerable’ at risk groups
defined below:

1. Pregnant
2. Over 70
3. Have a long-term health condition/ Underlying Medical Conditions as listed below:
• Chronic respiratory diseases, such as asthma, 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, a learning disability or cerebral palsy.
• Diabetes.
• Problems with the spleen, such as sickle cell disease or removal of the spleen.
• A weakened immune system due to conditions such as HIV and AIDS, or medicines such as
steroid tablets or chemotherapy.
• Being seriously overweight, (body mass index of 40 or above).

CONSENT TO RECEIVE CARE AT LIDO CHIROPRACTIC CLINIC

I have answered all questions (triage) relating to my potential exposure to Coronavirus (COVID19) truthfully; specifically I am not currently symptomatic, nor am I self-isolating, nor am I living
with anyone who is symptomatic or self-isolating, nor have I been in contact with anyone who
has or is suspected of having COVID-19.

I understand that there is a potential risk of transmission of Coronavirus (COVID-19) as a result
of attending the practice and/or receiving treatment.

I have had the opportunity to ask all the questions I wish to, and all my questions have been
answered to my satisfaction.

I have read, agreed to and understood the statements above relating to Coronavirus (COVID19) risk and consent to receive care at Lido Chiropractic Clinic.

I understand and agree that I will need to give separate consent regarding my chiropractic
care.