Clare Smith Acupuncture Covid 19 Consent Form

Every patient is required to complete this on the day of treatment for each appointment.

Additional information on the steps being taking by Clare Smith Acupuncture for Covid 19 can be found at claresmithacupuncture.com. This includes information regarding your treatment.

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* 1. Name

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* 2. Date of birth

Date

Date

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* 3. Email

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* 4. Address

Line 1 address

Line 2 address

Town

Country

Postcode

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* 5. Covid 19 Screening Information

	Yes	No
Have you had a fever in the last 7 days? (feeling hot to touch on your chest and back)	Have you had a fever in the last 7 days? (feeling hot to touch on your chest and back) Yes	Have you had a fever in the last 7 days? (feeling hot to touch on your chest and back) No
Do you now, or have you recently had, a persistent dry cough? (coughing a lot form more than an hour, 3 or more coughing episodes in 24 hours or worsting of a pre-existing cough).	Do you now, or have you recently had, a persistent dry cough? (coughing a lot form more than an hour, 3 or more coughing episodes in 24 hours or worsting of a pre-existing cough). Yes	Do you now, or have you recently had, a persistent dry cough? (coughing a lot form more than an hour, 3 or more coughing episodes in 24 hours or worsting of a pre-existing cough). No
Have you lost sensations of taste or smell?	Have you lost sensations of taste or smell? Yes	Have you lost sensations of taste or smell? No
Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid 19 or has coronavirus type symptoms?	Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid 19 or has coronavirus type symptoms? Yes	Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid 19 or has coronavirus type symptoms? No
Have you been told to stay home, self isolate or self quarantine?	Have you been told to stay home, self isolate or self quarantine? Yes	Have you been told to stay home, self isolate or self quarantine? No
Do you or anyone you live with fall into the 'clinically vulnerable' or 'clinically extremely vulnerable' categories as defined below	Do you or anyone you live with fall into the 'clinically vulnerable' or 'clinically extremely vulnerable' categories as defined below Yes	Do you or anyone you live with fall into the 'clinically vulnerable' or 'clinically extremely vulnerable' categories as defined below No

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* 6. Consent for treatment: 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

Yes

No

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* 7. I give consent to received treatment from Clare Venters Smith

I am the patient

I am the parent/guardian/carer