Language
  • English (US)
  • COVID-19 Health Information & 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.

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

  • 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
  • Consent for Treatment

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

  • 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.

  • Clear
  •  /  /
    Pick a Date
  • Clear
  •  /  /
    Pick a Date
  • Reflexology and Massage

    Member AMTA

    Member MCR & RAA

  •  
  • Should be Empty: