Covid-19 Informed Consent To Treat

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 the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.

To proceed with receiving care, I confirm and understand the following (Initial in all seven places provided)

I understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-toperson contact, in which COVID-19 can be transmitted.

I understand that I am opting for an elective treatment that may not be urgent or medically necessary. I understandthere are alternatives to receiving this care, which could including receiving care from another type of provider, orpostponing care altogether at this time. However, while I understand the potential risks associated with receivingtreatment during the COVID-19 pandemic,I agree to proceed with my desired treatment at this time.

I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristicsof procedures,I may have an elevated risk of contracting COVID-19 simply by being in a health care office.

I confirm I am not experiencing any of the following symptoms of covID-19 that are listed below:

Fever

Dry Cough

Sore Throat

Shortness of Breath

Runny Nose

Loss of Taste or smell

I understand that travel increases my risk of contracting and transmittingthe covID-19 virus. I verify that in thepast 14 days,I have NOT traveled: 1) Outside of the United States to countries that have been affected by COVID19; or 2) Domestically within the united States by commercial airline, bus, or train.

I am informed that you and your staff have implemented preventative measures intended to reduce the spread ofCOVID-19. However, given the nature of the virus,I understand there may be an inherent risk of becoming infectedwith COVID-19 by proceeding with this treatment. I hereby acknowledge and assume the risk of becoming infectedwith COVID-19 through this elective treatment and give my express permission to you and the staff at your offices to proceed with providing care.

I have been offered a copy of this consent form.

I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSuRE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION.

I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOTPOSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTloNS ABOUTITS CONTENT, AND BY SIGNING BELOW,I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMEDAPPROPRIATE FOR MY CIRCuMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FROM ALL PROVIDERS INTHIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE.

Patient Information

Patient Name

Patient DOB

Patient Signature

Guardian Information

Patient/Guardian Name

Patient/Guardian DOB

Patient/Guardian Signature

Witness Information

Witness Name

Witness DOB

Witness Signature

Phone Number

COVID-19 INFORMED CONSENT TO TREAT

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