COVID-19 Screening and Consent Form

Charlotte Mackintosh Visitors

To ensure the safety of our staff prior to each face to face appointment, please read the guidance regarding attending your appointment and complete the below screening questionnaire.

Appointment Guidance

Please do not enter reception, text or call your therapist to notify them of your arrival no more than 5 mintues prior to your appointment time, the telephone number is provided at the bottom of the form. Once you have notified your therapist please then approach the front door where your therapist will meet you (If your appointment is out of hours reception is not open/available).

Your therapist will greet you wearing a face mask or sheild in most cases, we request you bring a face mask/sheild for when using the corridors. During your appointment you are able to remove this if you feel distressed after we are seated in the therapy room, as we have a protective screen and distancing measures in place to ensure yours and our safety. If you are clinically vulnerable we encourage you to discuss this with us so we can consider the safest way to provide your support.

Your temprature may be taken using a infrared thermometer that is held at distance infront of your forehead by your therapist, if you are uncomfortable with this equipment being used or this may cause you distress please contact your therapist in advance of your appointment.

Upon taking a seat both therapists and visitors will be encouraged to use hand sainistiser at the start and end of the session.

Accessibility: Toilets are available for use by our visitors, there is a limit on the number of people using the toilets at any one time.

Your form message has been successfully sent.

You have entered the following data:

COVID-19 Screening Form

Please correct your input in the following fields:

Error while sending the form. Please try again later.

Name: *

E-mail address: *

Telephone: *

Please select if anybody who lives in your household has been diagnosed with coronavirus in the last 14 days

Please select if you or anybody in your household has been advised to self-isolate because you have coronavirus symptoms

Please select if you have been advised to self-isolate because you have been in close contact with someone who has tested positive for coronavirus

Please select if you or anyone in your household is/has been suffering from high temperature, new continuous cough or loss or change of sense of smell or taste

Please select if you been advised to self-isolate because you have entered the UK in the last 14 days

Captcha (spam protection code): *

*

I understand that this COVID-19 Screening form requests my name and contact details as in circumstances that COVID-19 diagnosis occurs, my details will be passed to NHS test and trace for my safety, the purpose of the meeting will not be disclosed, only that we have had contact.

Note: Fields marked with * are required

If you selected any of the above checkboxes we request that DO NOT under any circumstances attend your appointment, your appointment will be rescheduled, there will be no cancellation fees applied.

Your safety is our priority. Should your therapist display symptoms of COVID-19 symptoms they will cancel the face to face meeting and rearrange for 14 days later or change the session to a remote session if appropriate.

We understand some people may have reservations about returning to face to face appointments. Our risk assessment has been completed and we meet COVID secure workplace government standards, you are welcome to request a copy of pour risk assessment by speaking to your therapist who can forward this to you via email.

Arriving for your appointment, please text or call Charlotte Mackintosh 07421270732 we request no more than 5 minutes prior to your appointment time, Charlotte will then meet you at the front door within a few minutes.

Please note we are unable to see people earlier than their appointment time due to completing our rigorous cleaning procedures and ventilation of the room between appointments. Thank you for your co-operation, your safety is our priority as our face to face service resumes operation.