Covid-19 Risk Assessment & Declaration

Covid-19 Risk Assessment & Declaration Form

This form will be sent to you for completion 24 hours prior to face to face appointments.

Please complete this form up to 24 hours before you visit. If you’ve got any concerns or questions at all, then please contact us at

PLEASE NOTE: We are not currently accepting everyone. Your clinician will consider your personal risks and need for treatment. They will prioritise your health and have the final say as to whether they accept you for treatment.

What we’re doing to protect you:

We are taking a number of measures to protect you and our staff during this time. These measures include:

  • Adapting our opening times, appointments and reception areas to allow for social distancing and cleaning
  • Clinicians are wearing all appropriate PPE
  • Regular cleaning and disinfecting of all necessary surfaces between appointments
  • Considering and assessing each case individually to determine possible risks of Covid
  • We’re also promoting remote-treatment and self-help where appropriate (e.g. for those at high risk)

Do NOT come if you or anyone you live with has symptoms:

  • High temperature – your chest or back feel hot (you don’t need to measure your temp)
  • New, continuous cough – 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)
  • Loss or change of smell or taste

If you, or anyone you live with, have experienced any of these symptoms in the last 14 days, please DO NOT ATTEND and follow government guidance at

I confirm that I have NOT had any of the following symptoms in the last 14 days: fever, shortness of breath, loss of sense of taste or smell, dry cough:  (Y/N)

I confirm that to the best of my knowledge, I have NOT been in close contact with anyone with confirmed COVID-19 in the last 14 days. (Y/N)

Consider the risks:

The safest place during this pandemic is at home. Whenever you leave your home you increase the risk of catching Covid-19. Please reflect on this before coming.

People at higher risk should have had a letter from the NHS asking them to “shield” for 12 weeks, for example you’ve had an organ transplant or are on chemotherapy. If this is you or someone you live with, then you MUST speak to your therapist before coming in. You can learn more about who is at risk here:

There’s also a large group of people who are at moderate risk from coronavirus:

  • Are aged over 70
  • Are seriously overweight with a BMI of 40 or above (check at home if unsure)
  • Have a long-term lung condition (such as COPD, bronchitis or emphysema)
  • Have chronic heart, kidney or liver disease
  • Have diabetes
  • Have chronic neurological conditions (e.g. Parkinson’s, motor neurone disease or MS)
  • Have problems with your spleen (e.g. sickle cell)
  • Have a weak immune system (e.g. HIV, AIDS, steroids, immunosuppressants or chemotherapy)
  • Are pregnant

I confirm that I am, or anyone in my household is, NOT in the clinically extremely vulnerable category and therefore advised to shield at home by the government (Y/N - if N then contact clinician)

Travel and quarantine periods:

Please reschedule your appointment if you have travelled to any countries that require a quarantine period. Government guidance can be found at

I can confirm that I have NOT travelled to any countries that require quarantine within the last 14 days (Y/N)

What you need to do:

  • Please arrive on time for your appointment. If you are late you may miss your appointment and have to reschedule.
  • When you arrive, please stay in your car or wait outside, or if reception is available, please follow the social distancing guidelines.
  • Your clinician will come and collect you or call you to let you know we are ready for you.
  • Please bring a freshly laundered towel to your appointments (Chiropractic only).
  • Please leave loose items at home, including belts, phones etc.
  • Please arrive in clothes comfortable and ready for treatment.
  • Please wear your own mask or face covering. If not, one can be supplied for a £1 fee.
  • Please sanitise your hands using the hand gel on entering the building.
  • Please attend on your own, unless you are under 16 years old.
  • Please note that we will be taking card payments to prevent handling of cash.
  • Please leave the clinic immediately and as quickly as possible after your appointment.

I can confirm that I have read and agree to follow all of the above procedures (Y/N)

Covid-19 consent:

  • I understand and agree to follow all the statements on this form
  • I have considered the risk of transmission of Coronavirus as a result of attending the clinic and would like to attend
  • I understand Pure Health Chiropractic cannot accept responsibility for transmission of the Covid-19 should I become infected

Last updated 27th July 2020