Health Information: Covid-19 Consent Form

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Covid-19 Health Screening Information

    Have you had fever in the last 7 days?

    Do you now, or have you recently had, a persistent dry cough?

    Have you been told to stay home, self-isolate or self-quarantine?

    Do you have any other symptoms that may mean you have a Covid-19 infection?

    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 am

    If you are are signing on behalf of the patient, or if the patient is a minor, please state your relationship with the patient:


    Your name

    Your email