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Note: This form will be completed in-office. You'll only need to sign it once.

 

Consent for Treatment During COVID
 

To proceed with receiving care, I confirm and understand the following (initial in all places provided and sign at the bottom):

 

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 a variety of sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms yet still be contagious. _________ (initial)

 

I understand that I am the decision maker for my health care. To the best of their ability, my practitioner will provide me 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/risks associated with receiving bodywork during the pandemic. Given the current limitations of COVID-19 testing, I understand determining who is infected with COVID-19 is exceptionally difficult. ________ (initial)

 

I understand that preventative measures nd 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 acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my permission to Wendy Freiwald and Every Body Heals to proceed with providing care. ________ (initial)

 

I have been offered an electronic copy of this consent form. ________ (initial)

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