By filling in this form I understand that the coronavirus, COVID-19 has been declared a worldwide pandemic by the World Health Organisation and that COVID-19 is extremely contagious and is believed to spread person-to-person contact: and, as a result, social distancing is recommended. This is not entirely possible with my proposed treatment; however, I am satisfied that safety measures are in place to minimise risk as much as possible, and client contact will be kept to an absolute minimum in line with treatment need.

I understand that my therapist is closely monitoring the COVID-19 situation and have put in place reasonable preventative measures aimed at reducing the spread of COVID-19. However, given the nature of the virus, I understand that there is an inherent risk of becoming infected with COVID-19 and assume the risk of becoming infected through this treatment and I give my express permission to proceed.

I understand that COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I understand that COVID-19 can cause additional health risks, some of which my not currently be known at this time; in addition to those risk associated with the treatment itself.

I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19 and would like to proceed with my treatment.

We require your contact details in accordance with the Governments Track and Trace Policy and GDPR. Your details will only be shared with NHS Track and Trace and your contact details deleted after 21 days.

Are any of your family members or immediate/close contacts currently sick or experiencing: