Covid-19 Health Information and Informed Consent
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever of at least 100 degrees?
Have you or anyone in your household tested positive for Covid?
Have you or anyone in your household travelled anywhere outside the state with the exception of NH and VT, in the last two weeks?
Have you or anyone in your household travelled to Washington, Knox, Franklin or Somerset counties in Maine in the past two weeks??
Is anyone in your household a healthcare provider or emergency responder?
Can you exercise to get your heart rate and respiratory rate up without any problem?
Have you had a new onset of muscle soreness and pain since the emergence of the virus that is unexplainable?
Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin that is unexplainable?
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive?
Do you have any reason to believe you or anyone in your household has been exposed to or has aquired Covid?
To the best of your knowledge, have you been in close proximity to any individual who has tested positive for Covid?

Consent for Treatment

To proceed with receiving care, I confirm and understand the following:

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 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 understanding 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 the 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 in 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 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 OPPORTUNITIY TO ASK QUESTIONS ABOUT ITS 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 CONDITIONS FOR WHICH I SEEK CARE.  

By checking the following box, I am digitally signing Shannon Wong Massage's consent form and agree to all the policies and procedures.  

© 2020 by Shannon M. Wong. All Rights Reserved.

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