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TPFC Hydro Indemnity Form

This document contains an indemnity and screening form for users of a public hydrotherapy pool. It requires personal details from pool users and carers. It notes assistance cannot be provided for changing or transfers. It also states a declaration must be signed indemnifying the local borough for any injuries, and screening questions regarding medical conditions must be completed and approved by a medical professional if any issues are indicated.

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217 views

TPFC Hydro Indemnity Form

This document contains an indemnity and screening form for users of a public hydrotherapy pool. It requires personal details from pool users and carers. It notes assistance cannot be provided for changing or transfers. It also states a declaration must be signed indemnifying the local borough for any injuries, and screening questions regarding medical conditions must be completed and approved by a medical professional if any issues are indicated.

Uploaded by

venky_akella
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Hydrotherapy Pool

Indemnity & Screening Form


for Users of Public Sessions

Our pool - The Hydrotherapy Pool is for people who require supported
exercise as part of a rehabilitation programme for healing & recuperation.

Casual swimming is not permitted.


1. Personal details
Are you a pool user or caring for someone in the water? Pool User Pool Carer
Title: Full name: D.O.B: DD/MM/YYYY
House no.
Male Female
& street
Town (t) Home:
City/county Postcode: (t) Mobile:

Emergency contact name: (t)

2. About yourself and using the Hydrotherapy Pool


Please note the following:
 The centre cannot provide assistance for changing or transfer to and from the pool hoists
 If you weigh more than 24 stone and need to use a hoist we regret you will be unable to
use the pool
 If you are accompanied by a carer they may only enter the water in order to physically
support and aid you in your use of the pool
 Children under 12 months of age cannot use the Hydrotherapy Pool

3. Declaration by (or on behalf of) the Hydrotherapy Pool User


 I have indicated “Yes” or “No” against every item in the screening checklist overleaf
 If I am under 5 or over 69 I have obtained the consent of a Medical Practitioner
 If I have ticked “Yes” to any conditions listed overleaf I have obtained the signature and
stamp/surgery address of a Medical Practitioner (section 5)1
 I know of no other condition making use of the Hydrotherapy Pool unsafe
 I indemnify the London Borough of Richmond upon Thames (LBRuT) for all claims against
LBRuT in respect of any loss or damage caused by any event or accident causing personal
injury or loss of property to myself, other than those caused by LBRuT through negligence
or default, when I am using the Hydrotherapy Pool.

Signed: …………………………………….. Office use only


Member ID Date of issue Issuer
Date: ………………………………………..
Please tick here if you wish to receive marketing by:○ Mail ○ Email ○ SMS ○ Telephone
Privacy and Data Protection – For full details of our policy please visit: www.richmond.gov.uk/council/open_richmond/data_protection

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LBRuT reserve the right to seek further opinion before admittance to the Hydrotherapy Pool.
TPFC, Vicarage Road, Teddington TW11 8EZ, (t) 020 3772 2999 1 of 2
4. Screening checklist2: Hydrotherapy Pool user to complete for their medical professional
Please note: a “Y” or “N” answer must be provided for every item listed below.

Absolute contra-indications
Yes No Yes No
Severe cardiac disease Fear of water that cannot be overcome
st Within Radiotherapy/chemotherapy
Pregnancy – 1 trimester
programme
Medical instability following an acute episode
Known aneurysm
(within 3 months) i.e. stroke, DVT
(if a “Yes” is indicated for any of these the pool CANNOT be used)

Contra-indications
Yes No Yes No
Skin infections (excluding psoriasis & Severe asthma, chronic respiratory
eczema) conditions, shortness of breath
Wound infections, pressure sores, ulcers Bladder infections, frequent UTI’s
Unstable blood pressure/diabetes Pyrexia (increased temperature)
Influenza, respiratory tract infections Deep vein thrombosis, pulmonary embolism
Recent (within 3 months) surgery Gastric upsets, vomiting, diarrhoea
Increased frequency of seizures Acute pain, discomfort
Fractures/joint replacements within 3 months Kidney disease
I need to use the overhead hoist (supine)
Faecal incontinence uncontrolled
and am under 24 stone (160kg)
(if any of these are present the pool should NOT be used UNTIL condition/illness is either undergoing treatment
or has been treated, and medical clearance sought)

Precautions
Yes No Yes No
Cardiac or circulatory problems Skin conditions – eczema, psoriasis
Epilepsy Pregnancy beyond 1st trimester
Diabetes Neck or back problems
Warts, verrucae, Athlete’s foot Tubes (catheters, Hickman lines, fistulae)
PEG’s, PEJG (feeding tubes) Anxiety, stress
Mobility problems, falls Difficulties with transfers (carer required)
Osteoporosis Dementia
I need to use the pool-side hoist (seated)
Challenging behaviour
and am under 22 stone (140kg)
(if any of the these are present medical clearance MUST be sought)

5. Medical Professional Recommendation (of GP/Physiotherapist if a “Yes” is indicated above)


Dear Doctor/Physiotherapist,
The above named patient wishes to use the Hydrotherapy Pool during publicly
accessible sessions for rehabilitation purposes without the support of an Aquatic Therapist and due to the
indications marked “Yes” above we require medical recommendation.
Declaration: I agree that, given the indications & precautions above, the above named patient is suitable for,
and would benefit from, unsupported use of the Hydrotherapy Pool in public sessions for prescribed
exercise, and is recommended on medical grounds.
(i) Referring GP/Physiotherapist Name (Print name):

(ii) Position: (iii) Surgery stamp:


(Hand write address if no surgery stamp)

(iv) Signed: (v) Date:

Please note: recommendation for referral cannot be accepted without (i) to (v) completed fully

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Screening checklist originally sourced from LBRuT Learning Disability Service
TPFC, Vicarage Road, Teddington TW11 8EZ, (t) 020 3772 2999 2 of 2

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