Atharva Ayurvedic Exceptional Treatment status consent form

Atharva Ayurvedic Wellness Centre is being proactive in protecting and identifying individuals , who may present to our practice with possible exposure and to report is necessary regarding the current COVID-19 pandemic. we will need to avoid negative clients outcomes or we will need to avoid a situation that will have direct impact on the safety of the clients or the clinician providing the treatment, Please answer the following statement questions with yes or no.

1- Do you or The person you are inquiring about have any of the following symptoms, Severe Difficult breathing, Struggling for each breath, Difficulty in speaking one sentence, severe chest pain, having hard time in waking up, Feeling confused or loss of consciousness? *
2-Do you or you are inquiring about have any of the following symptoms, fever, new cough, sore throat, difficulty in breathing? *
3-Do you or the person you are inquiring about have any of the follo wing symptoms, Muscles ache, fatigue, headache, runny nose, lethargy?*
4-Have you been in contact in the last 14 days with someone who is confirmed to have COVID-19? *
5-Have you traveled outside of Canada in last 14 days?*
6- I consent to the services offered to me and that I have answered to the any and all the questions, truthfully and to the best of my knowledge.*
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