Coronavirus declaration and consent form

I confirm that I have not had any of the following symptoms in the last 14 days: fever, shortness of breath, loss of sense of taste or smell, dry cough, runny nose or sore throat.

Yes / No

 

If I experience any of the above symptoms in future I will not attend any appointments for 14 days following onset.

Yes / No

 

I confirm that I have not in the past 14 days been in close contact with anybody with the above symptoms.

Yes / No

 

I confirm that I have not travelled to any country or area that requires quarantine on return within the past 14 days

Yes / No

 

If in future I travel to any country or area that requires quarantine on return, I will not attend any acupuncture appointments within 14 days of doing so.

Yes / No

 

I understand that these measures also apply to my practitioner (Paloma Sparrow).

I have had the opportunity to ask all the questions I wish to and all of my questions have been answered to my satisfaction.

Yes / No

 

I understand that there is some increased risk in contracting coronavirus in attending an appointment and will not hold Paloma Sparrow, or the clinic where my treatment takes place, responsible should I contract Covid 19.

Yes / No

 

Informed Consent

Your signature below indicates that you agree to the above.

 

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Patient                                                                                 Date