FORMS | flic-spa

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

My body temperature is below 100°F

I am not experiencing Covid 19 symptoms (fever, body aches, cough, sore throat, shortness of breath, loss of sense of smell/taste, unexplained sores on the feet, non allergy related runny nose, new onset fatigue/chills)

I haven’t been in close contact with a Covid-19 patient in the last 14 days

I declare that the info I’ve provided is accurate & complete. I understand that COVID-19 is contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may be asymptomatic and remain contagious. 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 decisions. 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 may be exceptionally difficult. I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented by Flic Spa. However, because this work involves close physical proximity over an extended period of time in an enclosed space, there may be an elevated risk of COVID-19 transmission. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to Flic Spa to proceed with providing care. 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. By signing below, I agree with the current or future recommendations 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.

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Date

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