COVID-19 Release Form

Please correct the errors described below.


On March 11, 2020, the World Health Organization declared the COVID-19 disease a pandemic. As a result, many hospitals and surgery centers put a hold on all elective and non-urgent procedures and surgeries. This was part of an effort to optimize Hospital treatment capacity and to save personal protective equipment (PPE) for frontline healthcare workers. In Hawaii, there are sufficient PPE, and elective/non-urgent procedures and surgeries are resuming. However, there is still a risk for patients who visit a healthcare provider and for performing these procedures and surgeries during the COVID-19 pandemic. These risks include but are not limited to exposure to other patients, healthcare staff, and healthcare facilities.

Some patients have a higher risk of complications from COVID-19, including those with:

  • asthma
  • chronic lung disease
  • serious heart disease or problems
  • chronic kidney disease
  • chronic kidney disease
  • extreme obesity
  • a compromised or suppressed immune system
  • liver disease
  • pregnant
  • age 65 or older, or
  • nursing home or long-term care facility residents
  • risk yet to be discovered

I understand if I have one or more of these conditions, I may have a higher change for 1) getting COVID-19 and 2) health problems if I get COVID-19. I understand that these problems may be serious. I may have to be in the hospital for a long time and could even die. The risk of death in the State of Hawaii according to 17 April 2020 statistics from COVID-19 is approximately 1 person per 100,000 population.

There may be other ways to meet with your doctor and be treated. You could have a phone evaluation or a telehealth evaluation. These other options may or may not be right for you. This depends on your health problem and overall health. If remote assessment and treatment are not appropriate, your doctor will explain why you need an in-person visit. Medical and office staff may help your provider when you arrive and while you are evaluated and treated. They will follow state laws and recommendations from local, state and national health officials related to caring for patients during the COVID-19 pandemic. However, they cannot eliminate risks, especially for highrisk patients.

I understand that COVID-19 is contagious. It is most likely spread by person-to-person contact. I understand that my doctor and her staff will follow all laws and recommendations from local, state and national health officials. However, there are still risks or being infected with COVID-19 during an office visit, procedure or surgery. I agree to assume the risks, and I give permission for my doctor and the staff to conduct an office visit and/or perform a surgery on me.

I understand that possible exposure to COVID-19 before, during, or after my visit, procedure or surgery may result in: a COVID-19 diagnosis, a long quarantine or self-isolation, more tests, being in the hospital, intensive care treatment, intubation/ventilator support, short-term or long-term intubation, other complications and the risk of death. Also, after office visit, procedure or surgery, I may need to go to an emergency room or hospital for care. I have been given the option to wait until a later date to have my office visit and/or procedure/surgery.

I understand all of the risks, including but not limited to potential problems related to COVID-19, and I would like to proceed with the procedure/surgery.

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