Client Name: *

Date *

1. Have you been tested for COVID-19? *

*If so, when?

**What was the result?

2. In the last 14 days: have you been in contact with anyone who has been diagnosed with COVID-19 or has had coronavirus-type symptoms? *

3. In the last 14 days: Have you been asked to self-isolate or quarantine by a doctor or local public health official? *

4. In the last 14 days: Have you been somewhere with a high infection rate? *

5. Do you now, or have you recently experienced, any of the following as a NEW PATTERN since the beginning of the pandemic:

6. If you tested positive for COVID-19 or believe you may have had COVID-19, but were not tested: Has your medical doctor cleared you to return to work or to end self-isolation?

7. If you tested positive for COVID-19 or believe you may have had COVID-19, but were not tested: Has your medical doctor advised you to return to normal activity levels?

9. If you tested positive for COVID-19 or believe you may have had COVID-19, but were not tested: Are you taking any drugs to manage blood clotting?

10. If you tested positive for COVID-19 or believe you may have had COVID-19, but were not tested: What other long-term, post-infection complications continue to affect your life?

I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. *

I understand that I am the decision maker for my health care. To the best of their ability, my practitioner will provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.

I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to you and the staff at your offices to proceed with providing care.

I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION.

I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FROM ALL PROVIDERS IN THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE.

PLEASE PROVIDE AN ELECTRONIC SIGNATURE BELOW: