COVID-19 Pandemic Information and Physiotherapy Treatment Consent Form

This document contains important information about your decision to undertake a facetoface consultation during the COVID-19 public health crisis. Please read this carefully and let us know if you have any questions. This document will be an official agreement between us that you are providing informed consent to treatment and The Ryan Centre’s policies 

Data Protection:  

The Ryan Centre is professionally obligated to cooperate with the Covid-19 Test and Trace scheme. If requested, we may be required to provide the contact details of members. By attending treatment, you are agreeing to your details being shared for this purpose. 

How have we made our Centre ‘Covid Secure? 

To ensure The Ryan Centre is a Covid Secure space, we have put in place several measures. These include: 

  • Decluttering of space and spacing out of seating/waiting areas. 
  • Reduced capacity to essential staff and Members with appointments only. This limits the number of people in the building. 
  • Thorough cleaning of high use and treatment areas and any equipment used after every Member. 
  • Personal Protective Equipment. All staff will be wearing appropriate PPE in line with Public Health England and CSP guidance. All members will be asked to wear a face covering/mask when in the Centre. 
  • Maximise Ventilation. Windows and doors will be kept open when possible. 
  • Pre-screening. Covid screening and information about your medical background and symptoms will be gathered over telephone or email prior to your arrival. This will help us risk assess clients, ensure nobody with Covid symptoms is entering the Centre and this will also help reduce the time needed in the Centre to provide this information. 

When you attend your Centre appointment: 

  • Please wear a face covering when you attend for your treatment. 
  • Please arrive on time and try not to arrive more than 5 minutes before your appointment time. If you arrive too early, we may not be able to accommodate you in the waiting area. If you arrive late, we may need to cut your session short to allow for the arrival of the next Member. 
  • There is reduced access to the toilets so please use the toilet before you arrive. 
  • You will be asked to wash or sanitise your hands on arrival at the Centre. 
  • Please come alone. Only people with an appointment will be admitted into the Centre. If you require someone with you, we must be informed about this in advance and they will need to consent to our Covid screening questions and wear a mask. 

Your statement of consent: 

I consent to having facetoface physiotherapy treatment at The Ryan Centre. 

I understand that there is currently a public health crisis in the UK due to the COVID-19 pandemic. This virus has a long incubation period during which carriers may not show symptoms and still be contagious. 

I understand that it is transmitted through airborne respiratory droplets and through touching contaminated surfaces and then touching your face. This risk is increased by close contact (less than 1m+ distance). 

I understand that by using appropriate social distancing measures, PPE and correct infection control procedures, the risk of virus transmission is reduced but cannot be eliminated, meaning there is still a risk that I could become infected. 

I understand that Covid-19 can result in serious illness and death in a minority of cases, but this risk increases significantly for certain people. 

People at High risk include those who: 

  • have had an organ transplant 
  • are having chemotherapy or antibody treatment for cancer, including immunotherapy 
  • are having an intense course of radiotherapy (radical radiotherapy) for lung cancer 
  • are having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors) 
  • have blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma) 
  • have had a bone marrow or stem cell transplant in the past 6 months, or are still taking immunosuppressant medicine 
  • have been told by a doctor they have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD) 
  • have a condition that means they have a very high risk of getting infections (such as SCID or sickle cell) 
  • are taking medicine that makes them much more likely to get infections (such as high doses of steroids) 
  • have a serious heart condition and are pregnant 

People at moderate risk include people who: 

  • are 70 or older 
  • are pregnant 
  • have a lung condition that’s not severe (such as asthma, COPD, emphysema or bronchitis) 
  • have heart disease (such as heart failure) 
  • have diabetes 
  • have chronic kidney disease 
  • have liver disease (such as hepatitis) 
  • have a condition affecting the brain or nerves (such as Parkinson’s disease, motor neurone disease, multiple sclerosis or cerebral palsy) 
  • have a condition that means they have a high risk of getting infections 
  • are taking medicine that can affect the immune system (such as low doses of steroids) 
  • are very obese (a BMI of 40 or above) 

 I understand that Public Health England recommends social distancing of one metre between people who are not members of the same household, and this is not possible with facetoface physiotherapy.  

I am aware of the guidelines that physiotherapy care should be provided through remote consultations when possible. Facetoface physiotherapy treatments should be for conditions that are causing significant pain or dysfunction, are at risk of deterioration, that are causing limitation to ability to work or perform activities of daily living (including sleep disturbance) or emotional/psychological distress. I confirm I am seeking treatment for a condition that meets these criteria.  

I confirm that I have not had any of the following symptoms of COVID-19 within the last 14 days or knowingly been in contact with anyone with these symptoms:  

  • a high temperature  
  • a new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual) 
  • a loss or change to your sense of smell or taste

If I, or anyone I am in close contact with, develops any of these symptoms or have contact with anyone with these symptoms, I will inform the Centre as soon as possible and will not attend. I understand that this statement applies to ongoing treatment sessions and that it is my responsibility to report any changes in my health status to the Centre prior to attending any subsequent session. 

I confirm that I, or anyone I am in close contact with, have not returned to the UK from a foreign country within the last 14 days. 

I understand that I have the right to withdraw my consent at any time. 


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