This document contains important information about your decision to receive services in light of the 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, elaborating as needed:
1. Have you taken your temperature in the last 3 days? If so, what was it? ________Have you had a fever in the last 2 weeks of 100°F or above?
2. In the last three months have you had any respiratory or flu symptoms (including fever, chills, fatigue, sore throat, cough, headache/muscle aches, or shortness of breath)?
Are you experiencing any of these symptoms now?
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?
4. Based on the enclosed scale, what level of quarantining have you been doing in the last two weeks?
5. Have you traveled anywhere outside of the state in the last two weeks? Location(s):
6. Have you had a new loss of sense of taste or smell?
7. Can you exercise to get your heart rate and respiratory rate up without any problem?
8. What new onset of muscle aches and pains have you had since the emergence of the virus?
9. Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?
10. Are you on blood thinners or blood pressure medications? If so, what?
11. Do you have any other risks associated with Covid-19 including Type A blood? Obesity? Lung Issues? Heart condition? Autoimmune disease? Rheumatoid arthritis? Kidney problems? Diabetes? Liver disease? Other concerns? Please list below and over.
Other pertinent information that your therapist needs to know:
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 her 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 confined 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 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. 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 TERESA EISENLOHR FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE.
Client Signature: _______________________________________________ Date: __________
Parent or Guardian Signature (in case of a minor): ________________________ Date: _________