BRITTENY ASHER CONSULTING

Britteny S. Asher, M.S., SLP - CCC, Speech-Language Pathologist

Wendy Gunter, M.S., CCC-SLP Speech-Language Pathologist

Shannon Wagner, OTD, OTR/L Occupational Therapist

Deborah Ferguson, MOT, OTR/L Occupational Therapist

 I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.

I further acknowledge that Britteny Asher Consulting and Associates has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.

By submitting this form you acknowledge reading the following terms:

• I consent to receive treatment from Britteny Asher Consulting and Associates during the COVID-19 outbreak. I understand there is much to learn about the newly emerged COVID-19 including how it spreads and is transmitted. I understand that based on what is currently known about COVID-19 the spread is thought to occur mostly from person-to-person via respiratory droplets shared with close contact. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a prolonged period of time or by having direct contact with infectious secretions from someone with COVID-19. I understand that many carriers of COVID-19 may not show symptoms but may still be highly contagious. I understand that due to the unknowns of this virus, there is a risk in face to face evaluation and/or treatment and that I have an increased risk of contracting the virus from the environment or people I come into contact with during a face to face visit.
• I have read, asked questions I may have had and have been provided the answers to aid me in fully understanding the facts regarding COVID-19 related risks.
• I understand that telehealth services or postponing services are both options that are available to me.
• I give my consent for in office evaluation or services.

By signing below I agree that Britteny Asher Consulting and Associates has provided me the facts and that no one has given me any guarantees that I will not become infected with COVID-19.