INFORMED CONSENT FOR IN-PERSON SERVICES DURING THE COVID-19 PUBLIC HEALTH EMERGENCY
This document contains important information about our decision (yours and mine) to begin/resume in-person services in light of the COVID-19 public health crisis. Our decision is based in part on recommendations by the Center for Disease Control (CDC), but other factors may be considered. Some of these include but are not limited to: whether we and our families have been vaccinated, our health or the health of those we are in close contact with, and risk of exposure outside of this setting. There may be other concerns that we can talk about.
Risks of Opting for In-Person Services
You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service.
Your Responsibility to Minimize Your Exposure
To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, and our families, other patients, other people in the office, etc.) safer from exposure, sickness and possible death.
- You will only keep your in-person appointment if you are symptom free.
- You will only keep your in-person appointment if you have been fever free for a minimum of 10 days prior to our appointment.
- You will cancel your appointment if you have been in contact with someone who has tested positive within the last 14 days.
- You will take your temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to proceed using telehealth.
- You will wait in your car or outside until no earlier than 5 minutes before our appointment time.
- You will wash your hands or use alcohol-based hand sanitizer when you enter the building.
- You will adhere to safe distancing precautions.
- You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands.
- If you are bringing your child, you will make sure that your child follows all of these sanitation and distancing protocols.
- You will take steps between appointments to minimize your exposure to COVID.
- If you have a job that exposes you to other people who are infected, you will immediately let me know.
- If a resident of your home tests positive for the infection, you will immediately let me know.
I may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.
My Commitment to Minimize Exposure
My practice has taken steps to reduce the risk of spreading the coronavirus within the office. In the spirit of encouraging every individual to make their own health decisions, I do not require visitors to my office, staff, or other persons in my office, to be vaccinated. When you visit my office you must assume you will be in contact with unvaccinated people.
If You or I Are Sick
You understand that I am committed to keeping you, me, my staff and all of our families safe from the spread of this virus. If you show up for an appointment and I or my office staff believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate.
Your Confidentiality in the Case of Infection If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits.