I hereby acknowledge that I have agreed to meet with the Service Provider at The Facility (otherwise identified as “Moss Psychology”), for the purpose of receiving Psychological Services.
By agreeing to meet with the Service Provider and receive the Services, I am aware of the following:
There is a risk that I could be exposed to severe acute respiratory syndrome coronavirus 2, the virus responsible for COVID-19 (hereinafter referred to as “COVID 19”) while attending at the Facility to receive the Services. I accept and acknowledge that I could be exposed to COVID 19 through the following means (this list is not exhaustive):
a. My physical presence at the Facility;
b. My interactions with other patients or members of the public who are present at the Facility at the time of my attendance;
c. My interactions with staff, agents and other health care professionals at the Facility;
d. The physical touching of any equipment or fixtures in the Facility.
While receiving services, the Service Provider may need to be physically closer to me than the recommended social distancing guidelines in order to assess and/or treat me. I acknowledge that I have read and fully understand the risks as described above. I acknowledge and confirm that I am willing to accept these risks as a condition of attending at the Facility to receive the Services from the Service Provider. I confirm that any questions that I had regarding the provision of the Services during the COVID 19 pandemic have been answered by the Service Provider.
In order to minimize the risks to myself and others, I hereby consent to the following additional measures:
If I am experiencing any physical symptoms that could potentially be related to those identified as symptoms of COVID-19 I must inform reception prior to arriving for my scheduled appointment, and a remote session will be organized. If I fail to notify Moss Psychology of my symptoms prior to arrival, my appointment will be cancelled and I will be responsible for paying the full cost of the appointment.
I will not arrive more than 5 minutes before the start of my appointment. If I arrive earlier, I will wait in my vehicle/outside the building.
Prior to entering I must apply a face mask that covers my nose, mouth and chin. Upon entering the building, I must immediately sanitize my hands with the hand sanitizer provided. I will then check in with reception.
I will maintain a physical distance between myself and others in the building of at least 2 metres. The only exceptions are when interacting with staff behind plexiglass screens or when I consent to closer contact during assessment and treatment as detailed above.
At the end of the appointment, I will check out with reception and exit the building as soon as possible.