Have you had fever in the last 7 days? YesNo
Do you now, or have you recently had, a persistent dry cough?YesNo
Have you been told to stay home, self-isolate or self-quarantine? YesNo
Do you have any other symptoms that may mean you have a Covid-19 infection? YesNo
Consent for treatment: I understand that, because my treatment may involve touch and close physical proximity over an extended period time, there may be an elevated risk of disease transmission, including Covid-19. By sending this form I give my consent to receive treatment from Titta M. Laattala. I consentI do not consent
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