COVID-19 Questions & Informed Consent

This document contains important information about your decision to receive services in light of the COVID-19 public health crisis. Please read and fill out this form carefully and let me know if you have any questions.

Client Name:

Date:

Date

1. COVID-19 Information - Have you had a sudden recent loss of smell or taste?

Yes No

2. COVID-19 Information -Do you now, or have you recently had any respiratory or flu symptoms (including fever, chills, sore throat, cough, muscle aches, or shortness of breath)?

Yes No

3. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus -type symptoms?

Yes No

4. COVID-19 Information - Have you traveled outside of the state in the last two weeks?

Yes No

5. What counties do you live or work in?

6. Have you been tested for Covid?

Yes No If yes, I tested negative If yes, I tested positive

The following questions are specific to a new aspect of COVID-19 involving blood coagulation.

6. Can you exercise to get your heart rate and respiratory rate up without any problem?

Yes No

7. Have you had a new onset of muscle aches and pain since the emergence of the virus?

Yes No

8. Have you seen any new marks, rashes, bumps, or other esions on your skin?

Yes No

Please read the following carefully and sign consent statements. TY

According to the Centers for Disease Control and Prevention (CDC), people of any age with these underlying health conditions are at increased risk for developing severe illness from COVID-19.

People 65 years or older
Children who are medically complex with underlying health conditions
Women who are pregnant
People with neurologic conditions (e.g., dementia)
People with chronic obstructive pulmonary disease
People with pulmonary fibrosis
People with moderate to severe asthma
People with cystic fibrosis
People with serious heart conditions
People with hypertension (high blood pressure)
People with sickle cell disease
People with thalassemia (a type of blood disorder)
People with cerebrovacular disease (affects blood vessels and blood supply to the brain)
People undergoing cancer treatment
Bone marrow or organ transplant recipients
People with immune deficiencies from medications or use of corticosteroids
People with HIV/AIDS
People with obesity (BMI 30 or higher)
People with diabetes (type 1 and type 2)
People with chronic kidney disease and undergoing dialysis
People with liver disease
People who are smokers

To proceed with receiving care, I confirm and understand the following (Initial in all places provided)

I understand that COVID-19 is highly contagious and still present in the community where I am seeking massage therapy. I understand that COVID-19 is passed through close contact with others and that people without symptoms may be infectious. I understand that this massage and reflexology business has taken every precaution to ensure my health and safety but that risk of infection is still possible.

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 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.

I understand that in the event that a client or therapist of this facility tests positive for COVID-19 within a time period that places me at risk of exposure, my name and contact information will be shared with the State Department of Health for their follow-up. In the event that I develop symptoms of illness within two weeks of my massage appointment, I will contact this massage facility immediately. 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 have been offered a copy of this consent form.

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 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 FROM ALL PROVIDERS IN THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE.

Client Signature:

Clear

Date:

Date

Parent or Guardian Signature (in case of a minor):

Clear

Date:

Date

Reflexology and Massage

Member AMTA

Member MCR & RAA

COVID-19 Health Information & Informed Consent

Consent for Treatment