COVID-19 Pandemic Consultation/Treatment Consent Form
I knowingly and willingly consent to having an in-person consultation and/or procedure during the time of the COVID-19 pandemic and after. I understand in-person consultations and/or having my procedure performed at this time, despite my own efforts and those of my Doctor, may increase the risk of my exposure to COVID-19.
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by checking this box I understand and accept this statement.
To reduce the possibility of COVID-19 exposure or transmission at my Doctor’s office,I accept that my Doctor will implement infection-control procedures with which I must comply, before, during and after my consultation and/or procedure, for my own protection as well as that of my Doctor. I understand my cooperation is mandatory,whether or not I personally feel such COVID-19 procedures and/or preventive measures are necessary.
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by checking this box I understand and accept this statement.
I have informed my Doctor 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 procedure, I will immediately provide the results of that testing to my Doctor. I understand my Doctor 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 my Doctor, before I may receive my procedure.
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by checking this box I understand and accept this statement.
I confirm neither I nor any individual living with me has any of the COVID-19 symptoms listed by the Centers for Disease Control (www.cdc.gov) which website I have consulted; 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.
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by checking this box I understand and accept this statement
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it, and who does not give the current limits in virus testing.
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by checking this box I understand and accept this statement.
Arrival Policy
I agree to wear a cloth or surgical mask upon arrival to the office and I agree to arrive alone unless I discuss special circumstances with the office.
Screening Policy
I’m willing to take a temperature check and answer a brief series of questions about symptoms during my visit to the office before the services are started and I agree not to come to the office with the following symptoms of COVID-19 listed below: Fever- Temperature, shortness of breath, loss of sense of taste or smell, dry cough, runny nose, sore throat.
I have been given the opportunity to postpone my in-person consultation and/or procedure until the COVID-19 pandemic is less prevalent, but I choose to have my in-person consultation and/or procedure performed now.
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Yes
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