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Covid-19 Consent For Treatment
To proceed with receiving care, I confirm and understand the following

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 assit me in making informed choices.

I understand that preventative measure 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 diseases transmission, including Covid-19. care.

Parent or Guardian Signature{in case of a minor}

COVID-19 information

1.Have you had a fever in last 24 hours of 100°F or above
2.Do you now, or have you recently had, any respiratory or flu symptoms,sore throat,or shortness of breath?
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?

COVID-19 is a highly contagious virus that spreads from a person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventative measures have been put in place to further reduce the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected.

Consent for treatment:

Client Signature

Thanks for submitting!

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