I understand that I am consenting to an office visit/treatment/procedure/surgery that is/is not urgent or emergent. I also understand that the Coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization (WHO), and that COVID-19 is extremely contagious and is believed to spread by person-to-person contact. As a result, federal and state health agencies recommend social distancing.
I understand that my provider at Andover Eye Associates has put in place what are currently believed to be the most up-to-date, reasonable safety measures to help reduce the spread of COVID-19.
I understand that even If I have received a negative COVID-19 test result, the test may have failed to detect the virus, or I may have become infected after I took the test. I understand that even if I do not have any symptoms, I may have the COVID-19 infections, and that having the elective office visit/treatment/procedure/surgery can lead to a higher chance of complication and/or death.
I understand that exposure to COVID-19 before, during, and after my elective office visit/treatment/procedure/surgery could result in any of the following: a positive COVID-19 diagnosis, extended isolation, additional tests, and hospitalization (up to and including: the need for treatment In intensive care (ICU), short-term or long-term intubation, and other complication, and death)
I understand that COVID-19 may cause additional risks, some of which may not be known at this time, and that after my elective visit/treatment/procedure/surgery I may need additional care that may require that I go to an emergency department or hospital.
I understand that any elective treatment/procedure/surgery In Itself may also require additional care, which may require that I go to an emergency department, other specialist, or hospital.
I understand that this elective office visit/treatment/procedure/surgery may put me at increased risk for becoming infected with COVID-19. By signing this consent, I have accepted that risk and give my permission to proceed with office visit/treatment/procedure/surgery I have been given the choice to have my office visit/treatment/procedure/surgery at a later date. I understand the potential risk of delaying and want to proceed. I have read this consent, or someone has read it to me.