YOUR FAMILY'S HEALTH IS IMPORTANT TO ME. THAT IS WHY I AM TAKING THE FOLLOWING PRECAUTIONS TO KEEP YOU SAFE DURING YOUR VISIT:

I have received the Moderna vaccination series for Covid 19

FOR HOME VISITS:

I wear situation specific personal protective equipment
I ask that any unvaccinated adult present for the appointment wear a mask
Only necessary items are brought into the home
All items are wiped down immediately upon entering the home
I then wash my hands with soap and water
I use disposable gloves for hands on assessments
I carry hand sanitizer to use during the appointment
All items are wiped down at the end of the visit
I wash my hands again prior to leaving

FOR OFFICE VISITS:

I wear a KN95 mask
My office requires any adult entering the building to wear a mask
I wipe down high contact common areas upon arrival to my office
I wipe down all clinical items with fragrance free sanitizing wipes before and after every appointment
Used linens are laundered in between clients
I wash my hands with soap and water
I use disposable gloves for hands on assessments
I run a HEPA air filter at all times in my office. HEPA air filters effectively remove virus molecules, including Covid 19, from the air
I run a non ozone producing UV sterilizer in between appointments. UV sterilization effectively kills virus molecules, including Covid 19, on both hard and soft surfaces
Appointments are spaced a minimum of one hour apart to allow for adequate cleaning and in order to refresh the air in between cases
The buildings waiting area is closed, so I ask that you please call *the number provided on your reminder email* when you arrive so that I can come out to get you

WHAT I AM ASKING OF YOU:

Please be honest with me. I am not going to refuse care if you have had a recent exposure, or even if you are Covid positive. I will, however, institute the safety measures that best suit the situation. If you or a family member have Covid 19 symptoms, please allow me to set up a virtual meeting rather than an in-person one. If you have had a recent exposure please tell me so that I can determine the safest type of appointment to schedule, and the right PPE for that appointment. I am not only trying to protect myself and my family, but also the families who I will see after you.

SCREENING TOOL REQUIRED FOR CLIENTS:

TO BE COMPLETED WITHIN 24 HOURS PRIOR TO SCHEDULED CONSULT

Medical Questionnaire

Please fill out the following form completely and honestly. I will not cancel your appointment. This form allows me to determine the safest PPE to use!

Parents Name

Email Address

Child's Name

Date of Appointment

Have you or anybody in your household been diagnosed with Covid-19, been knowingly exposed to Covid-19, been tested for Covid-19, or been asked to quarantine in the past 14 days?

Yes

Do you or anybody in your holusehold currently have a fever, chills, cough, shortness of breath, sinus conjestion, sore throat, unexplained fatigue, headache, loss of taste or smell, body aches, nausea, vomiting, or diarrhea?

Yes

If you answered yes to any question, please elaborate

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete. I understand that care type may be modified, but care will not be denied, in response to my honest answers. I agree to notify Sara Hiland of Nourish Holistic Lactation Support if myself or a close contact of mine tests postivie for Covid-19 during the next 10 days.

Thanks for submitting!

Last updated May 30, 2021

Nourish, Holistic Lactation Support Expert Infant Feeding Assistance by a Board Certified Lactation Consultant In Home, In Office, Virtual - Breast and Bottle, Pumping Bedford, Manchester, Nashua, Concord NH Areas