Patient Advisory, Acknowledgment & Screening Form

I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

I understand that I am the decision maker for my health care. Part of this office’s role is to provide me with information to assist me in making informed choices. 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 that determining who is infected with COVID-19 is exceptionally difficult.

Please initial in each space provided, answer the pre-screening questions, and sign and date at the bottom of the form.

To proceed with receiving care, I confirm and understand the following:

I am informed that Kate Quinn Stewart has implemented preventative measures intended to reduce the spread of COVID-19 and complies with guidelines for infection control issued by the Centers for Disease Control and the local health department. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected with COVID-19 by proceeding with this treatment. I understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-to-person contact, in which COVID-19 can be transmitted. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment and give my express permission to you and the staff at your offices to proceed with providing care.

Initial*

I understand that I am opting for an elective treatment that may not be urgent or medically necessary, and that I have the option to defer my treatment to a later date. However, while I understand the potential risks associated with receiving treatment during the COVID-19 pandemic, I agree to proceed with my desired treatment at this time.

Initial*

I understand that Kate Quinn Stewart will only come to the office if she is symptom-free and, to the best of her knowledge, has not been exposed to the virus. However, other persons (including other patients, clients or residents or visitors in the building) could be infected, with or without their knowledge.

Initial*

I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of procedures, I may have an elevated risk of contracting COVID-19 simply by being in a health care office.

Initial*

Please initial in each space provided, answer the pre-screening questions, and sign and date at the bottom of the form.

To proceed with receiving care, I confirm the following:

I agree that if I have experienced symptoms and/or had a positive COVID-19 test within the 14 days prior to this treatment, I will notify Kate Quinn Stewart so that she can decide whether or not it is appropriate for me to receive in-person care. I understand that if in-person care is not appropriate for me at this time, I will have the option of rescheduling my office visit for a later date and/or doing a virtual visit in place of any office visit that must be cancelled due to infectious illness.

Initial*

I agree that if I begin to experience symptoms and/or receive a diagnosis of COVID-19 within 14 days of this treatment, I will notify Kate Quinn Stewart, L.Ac. so that she can take appropriate precautionary measures.

Initial*

I understand that if a local government COVID-19 contact tracer reaches out to Kate Quinn Stewart, L.Ac. about a potential exposure in her office, she will share the names and phone numbers of everyone who has been in her office during the period of time being investigated by the contact tracer. I consent to having my name and phone number shared in this way.

Initial*

I am aware that I have the option of printing or taking screenshots of this form or requesting that a copy of it be provided to me.

Initial*

I verify that I am not experiencing any of the symptoms of COVID-19 listed below:

o fever of greater than 100.0 F or feeling feverish

o chills

o shortness of breath

o dry cough

o runny nose

o sore throat

o loss of smell and/or taste

o sneezing / watery eyes / and/or sinus pain/pressure that is unusual and not related to allergies

o new rashes, bumps, or skin lesions with unknown cause

o red or purple bruise-like skin discolorations that are not caused by external injury

o chest pain, particularly when taking a deep breath

o vomiting or diarrhea (in the last 48 hours)

Initial*

Please also answer the following questions:

Within the last 14 days have you experienced any cold- or flu-like symptoms or any of the COVID-19 related symptoms listed above?*

YesNo

If "Yes," please describe the symptom(s).

In the last 2 months, have you been diagnosed with COVID-19?*

YesNo

If "Yes," when did you receive your diagnosis?

Have you had a positive result from a COVID-19 antibody test?*

YesNo

If "Yes," when did you receive your positive antibody test?

Are you currently awaiting the results of a COVID-19 test?*

YesNo

Is anyone in your household awaiting the results of a COVID-19 test?*

YesNo

Within the last 14 days, are you aware of having been in close contact (within 6 feet or less for longer than 10 minutes) with anyone who has been diagnosed with COVID-19?*

YesNo

To your knowledge, within the last 14 days, has anyone in your household been in close contact with someone who has been diagnosed with COVID-19?*

YesNo

Have you traveled domestically or internationally in the past 14 days?*

YesNo

If "Yes," where have you traveled?

If "Yes," when did you return home from your trip?

Name*

First NameLast Name

Date*

Date

By signing below, I affirm that my answers to the screening questions are true to the best of my knowledge and that I accept all risks inherent in receiving acupuncture treatment during a pandemic, as described above.

To sign this form, please draw your signature in the box either by using the mouse or trackpad on your computer, or by using your finger on the touchscreen of your phone or tablet.

Signature*

**Please be advised that if we need to reschedule your appointment due to any of the answers you have provided on this form, there will NOT be a late cancellation fee.**

Patient Screening for Receiving Acupuncture Treatment During the COVID-19 Pandemic

Pre-Screening Questionnaire