TO OUR PATIENTS: We are currently in the midst of a worldwide disease pandemic caused by the COVID-19 virus, also known as SARS CoV2. The Centers for Disease Control and World Health Organization have identified COVID-19 as a health threat that is both highly dangerous and highly contagious. The virus can be spread by any person-to-person contact including contact with healthcare providers. While the risks from the COVID-19 virus are expected to diminish with time, they are likely to be with us for a long time and there may never be a time when the risks from COVID- 19 are zero. Because of this, patients must be aware that their decision to proceed with an OFFICE VISIT, ELECTIVE SURGERY, PROCEDURE, OR TREATMENT carries an unavoidable risk that they might contract the COVID-19 virus.
At Southern New England Ear Nose Throat & Facial Plastic Surgery Group, LLP, we are taking many precautions to prevent the spread of the COVID-19 virus and to make our patients safe when they come to us for medical care. This includes training of our personnel, using appropriate personal protective equipment and adhering to guidelines published by major health organizations for the safe delivery of medical care. Despite this, however, the risks presented by the COVID-19 virus can never be eliminated. For these reasons, we are taking special steps to inform our patients about the risks, benefits and alternatives to receiving medical care during the COVID-19 pandemic.
CONSENT TO TREATMENT:
- I understand that choosing to receive elective medical care during the COVID-19 pandemic can result in a positive COVID-19 diagnosis for me or for those with whom I may come in contact, and may cause harm to me or to them including a positive COVID-19 diagnosis, additional tests, hospitalization that may require medical therapy, intensive care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications that may at present be unknown, and the risk of death.
- I understand that even though I may have received a negative test result for COVID-19, the test may have failed to detect the virus or I may have been exposed to the virus after the test.
- I have been given the opportunity to discuss the risks, benefits and alternatives available to me and to postpone my office visit, surgery, procedure, or treatment to a later date when the risks from COVID-19 may be lower.
- I have been given the opportunity to have my questions about COVID-19 risks addressed.
With these understandings, I choose to proceed with MY OFFICE VISIT, SURGERY, PROCEDURE, OR TREATMENT.
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.