Lucks'Yard'Clinic''
CONSENT'FORM'
COVID-19:'Risk'of'Transmission'
Lucks'Yard'Clinic'operates'with'very'strict'hygiene'and'sanitation'protocols'in'place'to'protect'our'
patients.''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
Despite'these'precautions,'there'is'an'inherent'risk'of'human-to-human'transmission'of'the'
Coronavirus'(COVID-19).''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
For'details'of'our'hygiene'and'sanitation'protocols,'please'speak'to'the'Practice 'M an age r.''
We'have'requested'any'symptom a tic'pa tients'to 'stay'aw a y'from 'th e'clinic'at'th is'time.'W h ilst'Luck ’s'
Yard'Clinic'has'taken'every'further'precaution'to'limit'your'risk'of'exposure'to'Coronavirus,'we'
cannot'guarantee'that'there'is'no'risk'to'you'as'a'result'of'attending'the'clinic'and/or'receiving'
treatment.''
How'does'coronavirus'spread?''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
This'virus'app ears'to'be'spreading'easily,'and'is'thought'to'spread'mainly'from'person-to-person'
through'peo p le'wh o 'are'in'close'contact'with'one'another'(within'about'6'feet)'or'through'
respiratory'drop lets'p rod uc ed 'wh en 'an 'infecte d'p erso n'co ug hs'o r'sne eze s.''
Whilst'it'is'currently'thought'that'people'are'm ost'contagious'when'they'are'm ost'symptomatic,'it'is'
possible'som e'spread'might'be'possible'before'people'show'symptoms.'
'
If'you'fall'in t o 'an y 'o f't h es e '‘H igh 'R is k’'c at e go r ies ,'yo u 'a r e's trongly'ad v ise d 'n o t't o 're ce iv e'c a re 'at 'th is '
time.'
You'are'in'the'at-risk'grou p'if'you 'are :'
Pregnant''
Over'70'
Have'a'long-term 'hea lth'co nd ition'o r'a'we ak 'imm u ne 'system '
Consent'to'receive'care:'
I'under st an d 't h a t'th e re 'is 'a'r isk 'o f'tr ansmissio n 'o f 'C o ro n a v iru s '(C O V ID-19)'as'a'result'of'
attending'the'clinic'and/or'receiving'treatment.''
I'under st an d 't h a t'L u ck ’s'Y a rd 'C lin ic 'ca n n o t 'ac ce p t 're sp o n s ib ility 'fo r 'tra n s m is sio n'of'the'
coronavirus'(COVID-19)'should'I'become'infected.''
I'have'ha d 't h e'c h a n ce 'to 'a s k'a ll'th e 'q u e s tio n s 'I'w is h 'to 'a t't h is'time.'
By'signing'the'above,'I'consent'that'I'have'read,'agreed'to'and'understood'the'statements'above'
and'consent'to'receive'care'at'Luck’s'Yard'Clinic.''
Patients'Name:…………………………………………………………………………………………….'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
Date:……………………………………………………… …………'
Signature:'
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