COVID-19 Consent Form

COVID-19 Knowledge and Consent

I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). Current knowledge is that it is extremely contagious, and that it has a long incubation period during which carriers of the virus may be contagious without showing any symptoms.

Given the current limitations of COVID-19 virus testing, I understand that determining who is infected with the virus is exceptionally difficult. To proceed with receiving care, I confirm and understand the following:

My treatment may create circumstances, such as the discharge of respiratory droplets, person-to-person contact or person-to-surface contact, during which COVID-19 can be transmitted. I understand that Jordan Van Voast has implemented preventative measures intended to reduce this likelihood. However, the inherent risk of infection remains.

I confirm that I am not experiencing any of the following symptoms that could be associated with infection of the COVID-19 virus: Fever, Shortness of Breath, Dry Cough, Sore Throat, Loss of Taste or Smell, and that I have not had close or direct contact with anyone displaying these symptoms, or who has tested positive for the virus, within the last fourteen days.

Travel increases my risk of contracting and transmitting the COVID-19 virus. I verify that I have not traveled in the past fourteen days by airplane, bus or train, or been around crowds of people. If so, I will discuss the circumstances (e.g. duration, density of crowd, mask wearing compliance) with Jordan or any practitioner he may employ at CommuniChi Acupuncture.

Having read and understood the information about Covid-19 in this document, I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment and give my express permission to Jordan and his staff to provide care.

CLIENT (print name)____________________________________


 (or client representative)    (Indicate relationship if signing for client)

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