COVID 19 CONSENT FORM

Your First Name (required)

Your last Name (required)

I knowingly and willingly consent to see Dr. Marina Yanover in person at Big Apple Health Center, to have acupuncture treatment or other procedures done, such as craniosacral therapy, cupping, microcurrent facial, and physical exams, during the COVID-19 pandemic.

Please Read and Acknowledge by checking ALL the boxes below:
I understand that COVID-19 has a long incubation period during which carries of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it given the current limits in testing. Because of that I have an elevated risk of contracting the virus simply by being in a public place such as doctor’s office.

I confirm that I am not presenting nor have I presented any of the following symptoms of COVID-19 listed below in the past 14 days: • Fever • Shortness of Breath • Dry Cough • Runny Nose • Sore Throat

Being fully informed, I accept the risk of COVID-19 exposure and I will bear the cost of any COVID-19 treatments required. I have been given the opportunity to postpone my in-person consultation and/or treatment until the COVID-19 pandemic is less prevalent, but I choose to have my in-person consultation and/or treatment performed now. If I am the parent or guardian or of the patient, I hold his/her health care power of attorney. I have read this COVID-19 Informed Consent Agreement and am authorized to consent on the patient's behalf.

I confirm that neither I nor any individual living with me has any of the COVID-19 symptoms listed by the Centers for Disease Control, neither I nor any individual living with me during the past 14 days has experienced any such symptoms; and that I and all persons living with me for the past 14 days have practiced all personal hygiene, social distancing and other COVID-19 recommendations contained within all governmental orders issued by my city and state. I understand I must honestly disclose this information to avoid putting myself and others at risk.

I have informed doctor Yanover of any COVID-19 testing I or any person living with me during the past 14 days has received, as well as the results of that testing, and if I am tested between now and the date of my visit or treatment at Big Apple Health Center, I will immediately provide the results of that testing to Dr. Yanover. I understand that Dr. Yanover may require that I be tested, possibly at my own expense and regardless of any prior testing, and that the results of that testing must be satisfactory to Dr. Yanover, before I may be allowed to visit Big Apple Health Center to receive my treatment.

I also understand in-person consultations and/or treatments performed at this time increases the risk of my transmission of COVID-19 to my Doctor. This virus has a long incubation period, there may be as yet unknown aspects of its transmission, and I realize that I may be contagious, whether or not I have been tested or have symptoms. To reduce the possibility of COVID-19 exposure or transmission at Big Apple Health Center, I accept that Dr. Yanover will implement infection-control procedures with which I must comply, before, during and after my consultation and/or treatment, for my own protection as well as that of Dr. Yanover and office staff. I understand my cooperation is mandatory, whether or not I personally feel such COVID-19 procedures and/or preventive measures are necessary.

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus and the CDC recommends social distancing of at least 6ft for a period of 14 days to anyone who has, which is not possible when performing acupuncture or other related treatments.

I verify that I have not traveled outside the United States in the past 14 days.

I verify that I have not traveled domestically within the United States or outside the surrounding Hill Country area by commercial airline, bus, train and car with the past 14 days.

I will inform Dr. Yanover if I nave used local public transportation such as trains, busses within past 14 days before my visit at Big Apple Health Center or if I have attended social gatherings, or if my job involves close contacts with other people.

As a health care professional, I believe that it is my responsibility to respond in a manner that prioritizes the health and well-being of our community, and I feel that this is the best way I can do so. Thank you for your cooperation in this matter.

Please sign in the box below:

Your Email (required)