COVID-19 Consent Form
Covid-19 screening information
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Shielding the extremely vulnerable*
People at moderate risk (clinically vulnerable) **
Consent for treatment
I declare that the information I have provided is correct to the best of my knowledge and I understand that, because my treatment may involve touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including Covid-19. I consent to the practitioner retaining the details provided on this form for a period of 7 years from today. I further understand that if I am under 18 years of age, these records will be kept until I reach the age of 25 (7 years after reaching 18).
*If you select Yes after reading this list, the practitioner should explain that you are classed as clinically extremely vulnerable and the government advise that you exercise ‘shielding’. People severely vulnerable to severe illness from COVID-19 (those with serious underlying medical conditions) will be provided with information and support on how to balance wellbeing and shielding.
**If you select Yes after reading this list, you are at moderate risk from coronavirus and it is very important you follow the advice on social distancing.
The way people are affected by the virus varies largely across different individuals. In terms of age, the impact will likely be most linked to level of frailty, strength of immunity and the presence of underlying conditions and ill-health, rather than a person’s exact age as a number alone. Individuals should see the risk as higher the older they are, but also be aware that this can vary from person to person. For this reason, we are no longer using any particular age as threshold in highlighting vulnerability to COVID-19.