Consent for Treatment

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Consent for Treatment - Covid19

To proceed with receiving care, I confirm and understand the following (initial in
after each statement and sign below):

Email *

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 their 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 virustesting, I understand determining who is infected with COVID-19 is exceptionally difficult. *

I understand that preventative measures and intensified sanitation protocol 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 hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to you and the staff at your offices to proceed with providing care. *

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 HAVE READ THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT. 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 FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE *

By typing my name and date below (Parent or Guardian in case of a minor), I am signing this consent for treatment waiver. *

A copy of your responses will be emailed to the address you provided.

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