COVID 19 Forms

Waiver of Liability: Care for Dawn’s Acupuncture Patients during the COVID-19 Pandemic

I/we have requested a resumption of my care at Dawn’s Acupuncture despite uncertainties related to the risks that I/we may be taking.  I understand that our current understanding of the COVID-19 virus, its transmission and risks to humans is incomplete and constantly changing.

What we do know is that COVID-19 is a highly contagious respiratory virus that can be transmitted by asymptomatic people.   It has been estimated that many of the patients who contract COVID-19 never have any symptoms, making it hard to protect everyone.

The known consequences of contracting the COVID-19 virus range from being asymptomatic to respiratory failure and death.  A variety of co-morbidities increase the risk of having a more severe course of infection but seemingly healthy young people can develop respiratory failure and die.  What determines the wide range of presentations is still a mystery to scientists and physicians.  Information on this virus is limited and evolving.  I

We understand that patients are capable of and do make risk assessment decisions for themselves every day.  This process is facilitated by the informed consent process.  There will never be a time when the risk of contracting this COVID-19 virus is zero but the risks are clearly higher in the earlier stages of the epidemic.

The following is a list of all health and age factors that are known to increase a person’s risk of getting serious complications from the flu (source: :

·       People 65 or older

·       People who live in a nursing home or long-term care facility

People of all ages with underlying medical conditions, particularly if not well controlled, including:

People with chronic lung disease or moderate to severe asthma
People who have serious heart conditions
People who are immunocompromised
o   Many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications

People with severe obesity (body mass index [BMI] of 40 or higher)
People with diabetes
People with chronic kidney disease undergoing dialysis
People with liver disease
Additionally here is a list of people at risk for influenza, who may want to also be cautious.  (Source:

·       Asthma

·       Neurological and neurodevelopment conditions

·       Blood disorders (such as sickle cell disease)

·       Chronic lung disease (such as chronic obstructive pulmonary disease (COPD) and cystic fibrosis)

·       Endocrine disorders (such as diabetes mellitus

·       Heart disease (such as congenital heart disease, congestive heart failure and coronary artery disease)

·       Kidney disorders

·       Liver disorders

·       Metabolic disorders (such as inheritied metabolic disorders and mitochondrial disorders)

·       People who are obese with a body mass index (BMI) of 40 or higher

·       People younger than 19 years of age on long term aspirin or salicylate-containing medications

·       People with a weakened immune system due to disease (such as people with HIV or AIDS, or some cancers such as leukemia) or medications (such as those receiving chemotherapy or radiation treatment for cancer, or persons with chronic conditions requiring chronic corticosteroids or other drugs that suppress the immune system.

Other people at high risk or influenza:

·       Adults 65 years and older

·       Children younger than 2 years old

·       Pregnant women and women up to 2 weeks after the end of pregnancy.

·       American Indians and Alaska Natives

·       People who live in nursing homes and other long-term care facilities

·       Although all children younger than 5 years old are considered at high risk for serious flu complications, the highest risk is for those younger than 2 years old, with the highest hospitalization and death rates among infants younger than 6 months old.

Understanding the above and, as an expression of my right to patient care and autonomy, I/we hold Dawn’s Acupuncture a harmless from any and all liability (including attorney fees and costs) for the consequences of receiving acupuncture and herbology treatments, whether mental or physical nature of character. I/We also do hereby accept any and all risks during the treatment of acupuncture and herbology and absolve, release, indemnify, protect and hold (Clinic Name) harmless from any and all liability (including attorney fees and costs) for the consequences of treatments done at Dawn’s Acupuncture whether mental or physical nature of character.

In signing this document, my/our questions have been answered to my/our satisfaction.


If a minor parent/guardian:_____________________________

Date: ________/________/__________



Dr. Dawn Mamikunian, L.Ac., DACM