COVID-19 Informed Consent

Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as "Coronavirus", at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so. Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness at our office, just as you might be at your gym, grocery store, or favorite restaurant.

1. I knowingly and willingly consent to be treated during the COVID-19 pandemic. I understand that the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and may still be highly contagious.

2. I confirm that I am not awaiting the results of a COVID-19 test.

3. I confirm that I am not presenting any of these COVID-19 symptoms:

Fever
Shortness of breath
Dry Cough
Runny Nose
Sore throat

4. I confirm that I have not knowingly been in contact with a person who has been diagnosed with COVID-19 within the past 14 days.

5. Is a care giver/guardian attending appointment with you today?

YES

Name

Phone Number

6. Have you received a COVID-19 Vaccine?

YES

If yes,

Pfizer Moderna Johnson & Johnson

Patient's Name

Date of Birth

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Today's Date

Your information will be encrypted.