Patient Name: __________________________________

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. 

I understand that due to the frequency of visits of other patients, the characteristics of the novel coronavirus, and the characteristics of acupuncture and or physiotherapy treatment procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in an acupuncture clinic.______(Initial)

 

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:

• Fever > 38° C ______(Initial) 

• New cough or worsening chronic cough ______(Initial)  

• Sore throat or painful swallowing ______(Initial) 

• New or worsening shortness of breath or difficulty breathing ______(Initial) 

• Difficulty breathing ______(Initial) 

• Flu-like symptoms ______(Initial) 

• Runny or stuffy nose ______(Initial) 

• Loss of sense of smell or taste ______(Initial)  

• Headache ______(Initial) 

• Chills ______(Initial) 

• Muscle or joint aches ______(Initial) 

• Feeling unwell in general, or new fatigue or severe exhaustion ______(Initial) 

• Gastrointestinal symptoms (nausea, vomiting, diarrhea or unexplained loss of appetite) ______(Initial) 

• Conjunctivitis, commonly known as pink eye. ______(Initial)  

I confirm that I am not in a high-risk category, including: diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, having active malignancy, or over age 65. (Initial) OR I fall into the following high risk category (_______________________) and my registered practitioner and I have discussed the risks, and I agree to proceed with treatment. ______(Initial) 

I confirm that I am not currently positive for the novel coronavirus. ______(Initial) 

I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus. ______(Initial) 

I confirm that I have not had close contact (without PPE) with a suspected or lab confirmed COVID-19 patient within the last 2 weeks. ______(Initial) 

I verify that I have not returned to Alberta from any country outside of Canada whether by car, air, bus or train in the past 14 days. ______(Initial) 

I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Alberta Health Services require self-isolation for 14 days from the date a person has returned to Canada. ______(Initial) 

I understand that Alberta Health Services has asked individuals to maintain physical distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive acupuncture and or physiotherapy treatment. ______(Initial) 

I verify that I have not been identified as a contact of someone who is suspected to be or has tested positive for novel coronavirus or been asked to self-isolate by Alberta Health Services, Health Canada, the Quarantine Act, the Communicable Disease Control or any other governmental health agency within the last 2 weeks. ______(Initial) 

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have an emergency or urgent acupuncture and or physiotherapy treatment during the COVID-19 pandemic.

 

SIGNATURE OF PATIENT ________________________________    

PRINTED NAME  ________________________________    

DATE: __________________________

Banyan Tree Health COVID-19 Informed Consent

© 2016 by KAYLA LAKUSTA, Creator and Dreamer of Banyan Tree Health