Health Information: Covid-19 Consent Form

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Covid-19 Health Screening Information

(Feeling hot to touch on your chest and back.)
(Coughing a lot for more than an hour, 3 or more coughing episodes in 24 hours or worsening of a pre-existing cough.)
(Loss of taste and smell, unusual fatigue or shortness of breath.)
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.
Full Name
DD/MM/YY
We will only contact you if there are problems with your screening form.