Patient Information and Consent Form

From 6th July - We are open for the following:

Chiropractic – Prebend St clinic and Goswell Rd
Podiatry – Goswell Rd only
Acupuncture – Goswell Rd only

Please click here for more details

Risk of Coronavirus (COVID-19) Transmission at Islington & Clerkenwell Chiropractic (ICC) Clinics

Please read this form, discuss with your chiropractor/podiatrist/therapist if necessary and sign where indicated. 

*This Form is in addition to consent form for chiropractic, podiatry or other therapy examination and treatment*

The Government published a Statutory Instrument on March 26th 2020, no. 350 ‘The Health Protection (Coronavirus, Restrictions) (England) Regulations 2020’, confirming that it is lawful for a chiropractic and podiatry practice to remain open. It further defines those people who are classed as ‘vulnerable’ – (please see below for more information in the eligibility section)

In accordance with up-to-date Government and Public Health England guidance Islington & Clerkenwell Chiropractic Clinics have taken precautions to protect our patients and team members.  These include rigorous sanitisation procedures.  We also request that any symptomatic patients follow NHS guidance on self-isolation and refrain from visiting the practice at this time.  Despite this, there is a risk of transmission of the Coronavirus (COVID-19) and it is important that you are aware of the risk.


Precautions that ICC Clinics have in place: –

  • All patients contacting us for an appointment are triaged by a member of our team over the telephone to establish their status (asymptomatic / symptomatic / self-isolating / living with someone symptomatic or self-isolating / have been in contact with anyone symptomatic). 
  • Only people in the asymptomatic category can attend the practice.
  • A team member conducts a second triage at the practice.
  • A strict cleaning, sanitation and infection control protocol is adhered to. 
  • All team members at Islington & Clerkenwell Chiropractic Clinics follow government social distancing guidance where possible.
  • Practice layout has been adapted to maintain social; distancing between patients and all team members where possible.


Eligibility for Treatment – (Can I come in for treatment?)

If you or someone you live with have been identified as vulnerable, or believe that you are vulnerable, we advise that you continue to shield at home.

Patients from the ‘vulnerable’ and ‘extremely vulnerable’ at risk groups will be offered a telephone consultation and advice.  If the practitioner deems it necessary to bring the patient in to the clinic, we will make extra precautions to make this as safe as possible for the patient.

This group includes: –

  1. Pregnant
  2. Over 70
  3. Have Long-term health conditions/underlying medical conditions listed below: –
  • Chronic respiratory diseases, such as asthma, COPD, emphysema or bronchitis.
  • Chronic heart disease, such as heart failure.
  • Chronic kidney disease.
  • Chronic liver disease, such as hepatitis.
  • Chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis, a learning disability or cerebral palsy.
  • Problems with the spleen, such as sickle cell disease or removal of the spleen.
  • A weakened immune system due to conditions such as HIV and AIDS, or medicines such as steroid tablets or chemotherapy.
  • Being seriously overweight, (body mass index of 40 or above).


Consent to receive care at Islington & Clerkenwell Chiropractic Clinics

  • I have answered all questions (triage) relating to my potential exposure to Coronavirus (COVID-19) truthfully; specifically I am not currently symptomatic, nor am I self-isolating, nor am I living with anyone who is symptomatic or self-isolating, nor have I been in contact with anyone who has or is suspected of having COVID-19.
  • I understand that there is a potential risk of transmission of Coronavirus (COVID-19) as a result of attending the practice and/or receiving treatment.
  • I have had the opportunity to ask all the questions I wish to, and all my questions have been answered to my satisfaction.
  • I have read, agreed to and understood the statements above relating to Coronavirus (COVID-19) risk and consent to receive care at Islington & Clerkenwell Chiropractic Clinics.
  • I understand and agree that I will need to give separate consent regarding my chiropractic care.