COVID-19 PATIENT INTAKE
Name *
Your Email Address *
Date of Birth *
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Things to Remember
1. Please be sure to ask your RMT any questions you have about this form or its contents BEFORE you sign this document
2. You have the right at any time to ask questions about your treatment
3. Please be sure to immediately advise your RMT if you become uncomfortable with any aspect of your treatment, so that they may stop and discuss it with you
Do you have a fever, a new cough, a worsening chronic cough, shortness of breath or difficulty breathing? *
Have you had close contact with anyone with acute respiratory illness or have you travelled outside of Canada in the past 14 days? *
Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19? *
Do you have 2 or more of the following symptoms: Sore throat, runny nose/sneezing, nasal congestion, hoarse voice, difficulty swallowing, decrease or loss of sense of smell, chills, headaches, unexplained fatigue/malaise, diarrhea, abdominal pain, or nausea/vomiting? *
If you are over 65 years of age and experience any of the following: delirium, falls, acute functional decline, or worsening of chronic conditions? *
I understand that while the therapist is following all of the health and safety guidelines outlined by the Registered Massage Therapists Association of British Columbia, the College of Massage Therapists of British Columbia, and the Provincial Health Officer and that they are taking all reasonable precautions to clean and disinfect the clinic and all the surfaces within the treatment room, there are no guarantees that I may not come into contact with COVID-19.
Informed Consent
In the current environment of Covid-19 risk, informed consent requires that the patient be informed and understands that:
1. Any massage therapy treatment involves some risk of Covid-19 cross- transmission.
2. The therapist is following protocols to help reduce or mitigate risk where possible, but that risk cannot be reduced to zero.
3. The patient consent to the treatment despite some risk.
4. The therapist will document the patient’s consent in advance and at every treatment.
Acknowledgment: I acknowledge and confirm that I have read and fully understand the content of this consent to treatment *
Required
Your Name *
Date *
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YYYY
*In the case of a person incapable of providing consent, signature of Parent or Guardian, in which case the Name & Relationship of Person Signing. Please sign the parents name below.
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