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Attestation to no known exposure

I understand that to be seen by my practitioner I must meet following criteria and, I attest that:

• I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain,* headache,* sore throat, or new loss of taste or smell.

              *chronic pain problems not included

• I have not traveled to a highly impacted area internationally or within the United States in the last 14 days.

              *You are exempt from quarantine if you have been fully vaccinated.

• To the best of my knowledge, I have not been exposed to someone with a suspected and/or confirmed case of the coronavirus/COVID-19.
• I have not been diagnosed with coronavirus/Covid-19 or not yet cleared as non contagious by state or local public health authorities.
• I am following all CDC recommended guidelines as much as possible and limiting my exposure to the coronavirus/COVID-19.

Clinic COVID-19 Policies

I have been informed that:

1. All practitioners using this office will be regularly tested for COVID-19 in compliance with the latest federal, state, and local guidelines.
2. If any practitioner using this office or if a patient recently seen in the clinic tests positive for COVID-19, all those who could have been exposed will be immediately notified. The clinic will close for 24 hours and be fully disinfected (or as directed by CDC current best practice recommendations) if any staff member or patient becomes ill and/or tests positive for COVID-19.
3. Patients are requested to notify their practitioner immediately if they test positive for COVID-19 and they have been recently been in the clinic.
4. All patients will be checked for fever before entering the clinic.
5. Patients must wear a mask during their appointments.* If you do not have a mask, one will be provided for you. If you do not wear a face covering, you will not be treated.
6. Patients are advised to proceed directly to a treatment room upon arriving at the clinic, and they will be requested to disinfect their hands upon entry.
7. All surfaces will be disinfected between patients, no items will be used between patients unless they can be fully disinfected. Disinfectant used:

   Product name : Bioesque Botanical Disinfectant Solution

   Product website

EPA Registration # 87742-1-92595

EPA Product Lookup Tool ; search: “87742-1”
Active Ingredient: Thymox (thyme oil extract, non-toxic).

1. Practitioners using this office will continue updating patients about its policy throughout the COVID-19 pandemic.

*If you are receiving acupuncture and fully vaccinated, you will be allowed to remove your mask during needle retention. HEPA filter will be running during and in between patient appointments. Rooms are ventilated by open window in between appointments for 10-15 minutes. 

By signing this form, I am certifying that:

1. I acknowledge the contagious nature of the coronavirus/Sars-Co-V2 and that the CDC and many other public health authorities still recommend practicing social distancing.
2. I acknowledge that East-West Integrative Wellness (a.k.a Paul F. Ryan) (EWIW-PFR) the office tenant, 302 5th Avenue Building Management (302 BM) and the 8th Floor Office Suite Principle, Mindful Ventures (MV) have put in place preventative measures outlined above to reduce the spread of the Coronavirus/COVID-19.
3. I further acknowledge that EWIW-PFR, 302 BM and MV can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, other practitioners on the floor and using this office, and other patients and their families.
4. I am choosing to participate with “in clinic” care.
5. I have been made aware of the options available and have determined that in-clinic acupuncture is essential to my best results.
6. I hereby release and agree to hold EWIW-PFR, 302 BM, MV harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of EWIW-PFR, 302 BM, MV, or that may otherwise arise in any way in connection with any services received from EWIW-PFR, 302 BM, MV. I understand that this release discharges EWIW-PFR, 302 BM, MV from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from EWIW-PFR, 302 BM, MV. This liability waiver and release extends to EWIW-PFR, 302 BM, MV together with all owners, partners, and employees.
7. I personally and solely accept the associated risk of disease transmission and potential consequences.

Contact Tracing Information

In compliance with New York State requirements for contact tracing, please provide us the following information for contact tracers to identify and contact you in the event a practitioner or other patient tests positive for Covid-19 and there is a risk to you.

By signing ths form, I give permission to my practitioner to provide my personal identifying information to New York State contact tracers and for contact tracers contact me by phone and text message in the event I may have been exposed to coronavirus infection.