Please Note: this form must be filled on the day of your visit.
I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:
#1. Do you have a cough?YesNo
#2. Do you have a fever now or have you in the past 14 - 21 days?YesNo
#3. Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?YesNo
#4. Are you experiencing shortness of breath or difficulty breathing?YesNo
#5. Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?YesNo
#6. Have you experienced recent loss of taste or smell?YesNo
#7. Are you over the age of 60?YesNo
#8. Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?YesNo
#9. Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)YesNo
#10. I understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-to-person contact, in which COVID-19 can be transmitted.YesNo
#11. I understand that I am opting for an elective treatment that may not be urgent or medically necessary, and that I have the option to defer my treatment to a later date. However, while I understand the potential risks associated with receiving treatment during the COVID-19 pandemic, I agree to proceed with my desired treatment at this time.YesNo
#12. I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of procedures, I may have an elevated risk of contracting COVID-19 simply by being in a health care office.YesNo
#13. I am informed that you and your staff have implemented preventative measures intended to reduce the spread of COVID-19. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected with COVID-19 by proceeding with this treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment and give my express permission to you and the staff at your offices to proceed with providing care.YesNo
I have read, or have had read to me, the above COVID-19 risk informed consent to treat. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by submitting this form, and signing at our office, I agree with the current or future recommendation to receive care as is deemed appropriate for my circumstance.
I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek care from this office.YesNo
or give us a call at 516-671-0817.
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