Patient Consent Form

Step 1 of 2

  • Patient Who Has the Appointment
  • Thank you for your continued trust in our practice. As with the transmission of any communicable disease likea 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 and Center for Disease Control guidelines to limit transmission of all diseases in our office and continue to do so. The World Health Organization has characterized the COVID-19 virus, also known as “Coronavirus,” as a pandemic. Our practice wants to ensure you are aware of the risks of exposure to COVID-19 associated with receiving treatment during this pandemic. Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge. To provide a safe environment for our patients and staff, this practice follows the applicable state and federal regulations and protocols for infection control, universal personal protection, and disinfection. However, due to the nature of the procedures we provide, it may not be possible to maintain social distancing between patients, doctors, and staff at all times.
  • I acknowledge that I have read the Notice above and that I understand and accept that there is an increased risk of COVID-19 exposure with treatment during the pandemic. I understand and accept the increased risk of COVID-19 exposure with treatment at this office. I also acknowledge that I could, or may have, exposure to COVID-19 from outside this office and unrelated to my visit here. I have read and understand the information stated above:

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