Covid-19 Consent Form Name* Date* MM slash DD slash YYYY In the past two weeks have you experienced or had exposure to anyone who has had respiratory symptoms such as difficulty breathing or shortness of breath?* Yes No In the past two weeks have you experienced or had exposure to anyone who has had persistent pain or pressure in your chest?* Yes No In the past two weeks have you exposure to anyone who experienced or had excessive fatigue or tiredness that’s not relieved by sleep?* Yes No In the past two weeks have you experienced or had exposure to anyone who had a temperature above 100*F?* Yes No In the past two weeks have you experienced or had exposure to anyone who had acute digestive issues such as abdominal pain, vomiting or diarrhea?* Yes No In the past two weeks have you experienced or had exposure to anyone who had recent loss of your sense of smell or taste?* Yes No In the past two weeks have you experienced or had exposure to anyone who had swelling or redness in one or more of your toes?* Yes No In the past two weeks have you experienced or had exposure to anyone who had conjunctivitis/pink eye?* Yes No Are you considered to be immunocompromised?* Yes No Have you recently traveled? If so, where?* If yes to any of the above, please explain:I understand that healthcare is not an exact science and there is no guarantee of results. When undergoing treatment during a public health crisis, there are risks to engaging in these services, and increased potential for infection or exposure despite best efforts at prevention. IN addition to the potential for unsuccessful results from Pilates and Intuitive body work itself, I knowingly and willingly consent to receive treatment in person and with hands-on contract from Heidi Weiss, MPH, FNTP, during the extent of the COVID-19 pandemic.* I agree I disagree This office is actively engaging in appropriate CDC, OSHA, Oregon state and local health authority recommendations regarding sanitizing, PPE and safety protocols to attempt to slow the spread of the COVID-19 virus.* I agree I disagree In order to minimize these risks, my provider is requesting additional information and informed consent. I consent to having my temperature taken prior to treatment if necessary, and understand that I am required to wear a face and nose covering upon entry to the treatment entry, waiting area and treatment space, and that I will be asked to wear it for the duration of the visit unless requested to remove it by my provider.* I agree I disagree In order to keep others safe, I am confirming that I do not present with any of the symptoms consistent with COVID-19 such as those on the intake screening form.* I agree I disagree I confirm that I have not travelled internationally or to cities with high outbreak numbers in the last 14 days.* I agree I disagree I confirm that I have not been diagnosed with COVID-19 or been in known, close contact with any person(s) diagnosed or suspected of the virus and awaiting test results.* I agree I disagree I have tested positive for Covid antibodies within the past 14 days.* Yes No If yes, on what date did you test positive? I understand that COVID-19 can have a long incubation period in which, at times, virus carriers may be asymptomatic and yet still highly contagious. I understand that it is impossible to determine who is a carrier or not given the limitation in current testing, and that it is possible that my healthcare provider may be an asymptomatic infected carrier and not aware of it.* I agree I disagree Procedures done at this office can always present the potential for transmission of the virus, regardless of sanitizing protocols followed, masks and PPE worn, and all regulation procedures followed.* I agree I disagree I understand that by consenting to receive in person care at Portland Pilates Collective + Wellness Center, that I accept the potential for elevated risk of contracting the virus, simply by being in a healthcare setting.* I agree I disagree If I cannot truthfully agree to the above statements, Portland Pilates Collective + Wellness Center/Heidi Weiss has encouraged me to contact my Primary Healthcare Provider or the public health department to determine if I should be seen or tested prior to appearing in this office.* I agree I disagree Client named and signed below indemnifies Portland Pilates Collective + Wellness Center/Heidi Weiss and all parties related to this practice, location and practitioner of any harm, contraction of virus, disease, injury or death as a result of appearing in person for treatment or treatment itself. Please type your full name to sign.Date MM slash DD slash YYYY
