In order to treat you, we need to have your consent. In addition to our traditional general consent form, we require that you complete a specific Covid-19 consent to treat you during this era in our lives.
We are using this form to capture your consent. Your responses (initials and signature) will be emailed to us when you submit the form. We must receive this form 48 hours before your appointment.
COVID-19 INFORMED CONSENT TO TREAT FORM
I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.
I understand that I am the decision maker for my health care. Part of this office’s role is to provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given
To proceed with receiving care, I confirm and understand the following (Initial in all seven places provided):