Covid-19 Health Information & Informed Consent
This document contains important information about your decision to receive services in light of COVID-19 public health crisis. Please read and fill out this form carefully and let me know if you have any questions
COVID-19 Information - Please answer these COVID-19 health questions below:
1. Do you currently have a fever or had a fever in the last 24 hours of 100°F or above?
Yes ☐ No ☐
2. Do you now, or have you recently had, any respiratory or flu symptoms (including fever, chills, sore throat, cough, muscle aches, or shortness of breath)? Yes ☐ No ☐
3. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?
Yes ☐ No ☐
4. Have you traveled anywhere outside of the state in the last two weeks? Yes ☐ No ☐ If yes, location:
5. Have you had a new loss of sense of taste or smell? Yes ☐ No ☐
6. Can you exercise to get your heart rate and respiratory rate up without any problem? Yes ☐ No ☐
7. Have you had a new onset of muscle aches and pain since the emergence of the virus? Yes ☐ No ☐
8. Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin? Yes ☐ No ☐
Consent for Treatment
To proceed with receiving care, I confirm and understand the following (Initial in all places provided) 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 have been offered a copy of this consent form. _____________ 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 AND RISKS ASSOCIATED WITH MASSAGE THERPAY. 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.
Client Signature: _________________________________________________ Date: ____________
Parent or Guardian Signature (in case of a minor): _______________________ Date: ____________