Covid Consent Form

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Covid Consent Form

Name *

Date *

Date of Birth *

I, ____________________, (Print Name of Patient or Parent if Minor) knowingly and willingly consent to receive Acupuncture / Moxibustion and any adjunct TCM treatment during the COVID-19 pandemic. I understand that my treatment may create circumstances, such as the discharge of respiratory droplets or person to person contact in which COVID-19 can be transmitted and that the COVID-19 virus has a long incubation period during which asymptomatic carriers of the virus may not show symptoms and still be contagious. It is impossible to determine who has it and who does not given the current limits in virus testing. By completing this form and checking the box below, I acknowledge that while the risk of contracting the virus will be mitigated by following all of the safety and disinfection protocols as outlined by the CDC, WHO and Dana DePaul Ellis Acupuncture, I also understand and acknowledge that the risk of contracting the virus cannot be completely eliminated as is true of anywhere I go or any appointment I have outside of my home. I agree to keep Dana DePaul Ellis, L.Ac updated as to any changes in my medical state and understand there shall be no liability on the practitioner's part should I fail to do so. *

I consent to treatment & acknowledge all the above

Required

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

Yes, I acknowledge the above

By checking box below, I acknowledge that I have been informed that Dana DePaul Ellis, L.Ac has 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 treatment and I hereby acknowledge and assume this risk through this elective treatment and give my express permission to Dana DePaul Ellis, L.Ac to proceed with providing care

Yes, I acknowledge and agree to all of the above

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By signing (writing my name below) 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 had read to me, the above COVID - 19 risk informed consent to treatment. I appreciate that it is not possible to consider every possible complication to care. I have had the opportunity to ask questions about the content of this consent and by signing my name 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 this practitioner in this office for my present condition and for any future condition(s) for which I seek care from this office.

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