Thank you for your continued trust in our practice. There is nothing more important to us than your health and safety during this unprecedented time.
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. We are taking preventative measures and have implemented protocols, guided by the CDC, to help protect our patients and staff. Among other things, all patients are screened upon arrival for their appointment to make sure they are not exhibiting any symptoms. If a patient presents with COVID-19 symptoms, they will be advised to return home and contact their primary care physician. It is important that you provide honest answers to the screening questions and that you accurately report your health condition so that we can help protect you and others from the further spread of the virus to the extent possible.
Although we are taking precautionary measures to help minimize the risk of COVID-19 exposure,it is simply not possible to completely mitigate those risks. There is consequently a risk that youcould be exposed to COVID-19 during your visit to our office and that you could contract COVID-19 either during the course of your visit or while traveling to or from your appointment, just asyou might be at your grocery store or favorite restaurant.
The risks of COVID-19 include, but are not limited to, respiratory problems and othercomplications which could result in death. It is consequently important that you carefully considerthe risks and benefits of keeping your appointment given the risks associated with COVID-19.
The CDC recommends that patients who are over the age of 65 or who have health conditions thatmake them particularly susceptible to complications if contracting COVID-19 to remain at homeand to reschedule their medical appointments for a later date. If you do not feel comfortablekeeping your appointment, we will gladly reschedule your appointment for a later date.
Patients who desire to move forward with their treatment are being asked to confirm in writingthat they are aware of the risks to them of COVID-19 and to acknowledge that they neverthelessdesire to proceed with their appointment.
By my signature below, I acknowledge that I believe it is in my best interest to proceed with myappointment. I acknowledge that there is no way for the practice to fully mitigate or eliminate therisks of COVID-19 exposure, and I understand that, by proceeding with my appointment, I am atrisk for contracting COVID-19 and that a COVID-19 infection could cause serious health issues,including death. I nevertheless wish to proceed with my appointment, and I hereby waive andrelease the practice to the fullest extent permitted by law from any and all liability arising out ofor relating to my potential exposure to COVID-19 as a result of my appointment or the treatmentI may receive during my office visit.