New Patient Advisory and Acknowledgment Regarding Receiving Acupuncture Treatment During the COVID-19 Pandemic

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 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 Kate Quinn Stewart to proceed with providing care.

I acknowledge that while Kate Quinn Stewart can set policies and take preventive measures against the spread of illness within her personal office space, I may encounter other tenants of and visitors to the 1633 Q building and to Suite 200 who may or may not take similar precautions.

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 recently had a high-risk exposure to COVID-19. However, other persons (including other patients, clients, tenants, or visitors in the building) could be infected, with or without their knowledge.

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.

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.

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.

By signing below, I affirm 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.