COVID-19 Screening

Name *

First Name Last Name

I understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-to person contact, in which COVID-19 can be transmitted. *

Initial

I understand that I am opting for an elective treatment that may not be urgent or medically necessary, and that I have the option to defer my treatment to a later date. However, while I understand the potential risks associated with receiving treatment during the COVID-19 pandemic, I agree to proceed with my desired treatment at this time. *

Initial

I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of procedures, I may have an elevated risk of contracting COVID 19 simply by being in a health care office.

Initial

I understand travel increases my risk of contracting and transmitting the COVID-19 virus. I verify that I have NOT in the past 14 days traveled: 1) Outside of the United States to countries that have been affected by COVID-19; or 2) Domestically within the United States by commercial airline, bus, or train. *

Initial

I am informed that you have implemented preventative measures intended to reduce the spread of COVID-19. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected with COVID-19 by proceeding with this treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment and give my express permission to you and the staff at your offices to proceed with providing care. *

Initial

I understand that Public Health guidelines and this office policy does not allow for guests, I will need to come alone to my appointment and that no one will be able to join me at my appointment. *

Initial

I confirm I am not experiencing any of the following symptoms of COVID-19 listed: Fever, shortness of breath, dry cough, sore throat, runny nose, loss of taste or smell *

Initial

I understand that both the therapist and myself are required to wear a mask during the session with the exception to when I am in prone position (faced down). *

Initial

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 THE THERAPIST FROM THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE.

Patient Signature/Parent-Guardian Signature Clear

By attending my appointment:

I agree that I am not currently experiencing any of these symptoms:

Cough
Shortness of breath or difficulty breathing
Fever
Chills
Sore throat
New loss of taste or smell

Please note: Other less common symptoms have been reported, including gastrointestinal symptoms like nausea, vomiting, or diarrhea.

I agree that I have not:

Tested positive for COVID-19
Knowlingly been exposed to someone with COVID-19
Recently traveled to an area with high infection rate
Been in an area where social distancing was not properly observed
Been to a nursing home

If you have experienced any of the above, please reschedule your appointment at least 14 dyas from now.

I understand that both the therapist and myself are required to wear a mask during the session with the exception to when I am in prone position (faced down).

I have read/reviewed the Safety Standards and agree to it.

Date *

Date

I agree that I have not experienced any of the above and agree to the Safety Standards

Patient Signature/Parent-Guardian Signature Clear

Email

If you'd like a copy of this consent, please provide your email address. (Email is for sending a copy of this consent only).

COVID-19 SCREENING