Consent Form Information

Our clinic has instituted some new procedures to minimise risk of transmission of Covid-19. I would appreciate it if you could answer the following questions: 

In the last seven days: 

  1. Have you had a high temperature? (this can mean feeling hot to touch on your chest and back – you do not need to measure your temperature).
  2. Have you had a new continuous cough? (this means coughing a lot for more than an hour or three or more coughing episodes in 24 hours – if you usually have a cough, it may be worse than usual).
  3. Have you lost sensations of taste or smell?
  4. Have you had close contact (under 2 metres) with anyone with a confirmed Covid-19
    diagnosis or someone exhibiting the above 3 symptoms in the last 14 days.
  5. Have you recently travelled abroad and/or been instructed by the government to
  6. Have you been contacted by the government or NHS and told to self-isolate for any
  7.  Do you fall under the clinically vulnerable category or the clinically extremely
    vulnerable category (see below)?
  8. Do you live with someone who is in either the clinically vulnerable category or
    the clinically extremely vulnerable category (see below)?
  9. I have taken the necessary government mandated steps of conducting a risk assessment and instituting new social distancing, hygiene, hand-washing and PPE procedures in my practice to minimise the risk of Covid-19 transmission. In the course of the consultation I will have to have non-socially distanced contact with you to perform the treatment, hence while I will meet very high standards of infection protection control, it is impossible to completely eliminate risk. Please let me know that you understand this and are happy to proceed with the treatment.

Clinically vulnerable people 

People in this category of risk include:

  1. Anyone aged 70 and older (regardless of medical conditions).
  2. Anyone under 70 with an underlying health condition (that is, anyone instructed to get a flu jab as an adult each year on medical grounds) – such as:
  • Chronic (long-term) mild to moderate respiratory diseases, such as asthma, chronic
    obstructive pulmonary disease (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 (MS), a learning disability or cerebral palsy.
  • Diabetes.
  • A weakened immune system as the result of conditions such as HIV and AIDS, or medicines (such as steroid tablets).
  • Being seriously overweight (a body mass index (BMI) of 40 or above).
  • Pregnant women.

Guidelines for returning to work June 2020 Page 39 of 47 

© The British Acupuncture Council and the Register of Chinese Herbal Medicine 


Clinically extremely vulnerable people 

People in this category of risk include:

  1. 1 Solid organ transplant recipients.
  2. People with specific cancers:

    people with cancer who are undergoing active chemotherapy.
    b. people with lung cancer who are undergoing radical radiotherapy.
    c. people with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment.
    d. people having immunotherapy or other continuing antibody treatments for cancer.
    e. people having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors.
  3. People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe chronic obstructive pulmonary disease (COPD).
  4. People with rare diseases that significantly increase the risk of infections (such as severe combined immunodeficiency (SCID), homozygous sickle cell).
  5. People on immunosuppression therapies sufficient to significantly increase risk of infection.
  6. Women who are pregnant with significant heart disease, congenital or acquired.
  7. Other people have also been classed as clinically extremely vulnerable, based on clinical judgement and an assessment of their needs. GPs and hospital clinicians have been provided with guidance to support these decisions.

Please print out and fill in consent form, then bring along to the clinic:

– Covid Consent Form –