Patient Advisory and Acknowledgement Receiving Acupuncture Treatment During COVID-19
Dear Patient,

You have presented to the office today out of your own willingness to be treated with acupuncture. Please be advised of the following:

While our office complies with State Health Department, CDC and prevention infection control guidelines to prevent the spread of COVID-19, we can not make any guarantees.

Our staff are symptom-free and , to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, please complete the below questions. FOr the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
Do you have fever? *
Required
Do you have any shortness of breath? *
Required
Do you have a dry cough? *
Required
Do you have a runny nose? *
Required
Do you have a sore throat? *
Required
Within the last 14 days, have you traveled to another country? *
Required
In the past week, have you lost the ability to be able to smell and/or taste? *
Required
Your name (Type in as your signature) *
Date *
MM
/
DD
/
YYYY
Current Temperature (For office use only)
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