Coronavirus Client Declaration Form

Name *

First

Last

Email *

Numbers

Elective Treatment

Covid-19 Risk

I understand that the novel coronavirus, COVID-19, is extremely contagious and is believed to spread by person-to-person contact; and, as a result, social distancing is recommended. This is not entirely possible with my proposed treatment, however, I am satisfied that safety measures are in place to minimise rist as much as possible.

Covid-19 - Prevention Measures

I understand that the therapist has put in place extensive preventative measures aimed to reduce the spread of Covid-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with Covid-19 by virtue of proceeding with treatment. I hereby acknowledge and assume the risk of becoming infected with Covid-19 through this elective consultation/treatment, and I give my express permission to proceed.

Treatment Permission

I declare that the information I have provided is correct to the best of my knowledge and I understand that, because my treatment may involve touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including Covid-19. I have been given the option to defer my consultation/treatment to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to Covid-19, and I would like to proceed with my desired treatment.

Wellness Declaration

I confirm that I am not presenting, and I have not in the last 10 days presented, with any of the following symptoms of Covid-19: fever, shortness of breath, loss of sense of taste or smell, dry cough, runny nose, sore throat. If you have one or more of these symptoms, please contact us by phone or email.

Travel Declaration

I understand that air travel significantly increases my risk of contracting and transmitting the Covid-19 virus. I confirm that I have not travelled in the past 10 days.

Contact Tracing

I confirm that if I develop Covid-19 symptoms following my medical consultation or a known contact of mine develops symptoms, I will immediately inform the therapist to enable appropriate measures to be put in place and contact tracing to commence.