COVID-19 Treatment Consent Form
Name
*
First Name
Last Name
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms but still be contagious.
*
Please Select
YES
NO
I confirm that I am NOT presenting with any of the following symptoms of COVID-19: A fever (Higher than 38 degrees Celsius), a new cough or a regression of a chronic cough, a sore throat that is not related to a known or pre-existing condition, a runny nose that is not related to a known or pre-existing condition shortness of breath that is not related to known or pre-existing condition, a recent loss of taste or smell current flu-like symptoms such as nausea, vomiting, or diarrhea.
*
Please Select
YES
NO
I confirm that if I am in a high risk category including: diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, having active malignancy, or over the age of 65, I have discussed the risks with my therapist and I agree to proceed with treatment.
*
Please Select
YES
NO
I confirm that I am NOT currently positive for the novel coronavirus.
*
Please Select
YES
NO
I confirm that I am NOT currently waiting for the results of a laboratory test for the novel coronavirus.
*
Please Select
YES
NO
I confirm that I have NOT returned from any country outside of my hometown in the past 14 days.
*
Please Select
YES
NO
I confirm that I have NOT been in close contact with someone who has tested positive for the novel coronavirus or someone who has been required to self-isolate within the last 10 days.
*
Please Select
YES
NO
I verify the information I have provided on this consent form is truthful and accurate. I knowingly and willingly consent to having treatment.
*
Please Select
YES
NO
Signature
*
Submit
Should be Empty: