COVID-19 Informed Consent To Treat Form

COVID-19 Informed Consent To Treat Form
I understand that the infection caused by Coronavirus, otherwise known as COVID-19, is a contagious virus that has been declared a global pandemic by the World Health Organization (WHO). I also understand that there are persons who are considered asymptomatic who may not show any symptoms of COVID-19 infection, and yet, may still be as contagious as those who are manifesting symptoms of COVID-19.
I understand that it is my responsibility to choose my own healthcare provider and likewise my responsibility to make informed choices from my understanding of the informed consent that I receive which involves the agreement with regard to healthcare recommendation, and the risks and benefits associated with the treatment.
For the purpose of treatment, I acknowledge the following:
I understand that during treatment there is risk that I may be exposed to COVID-19 that may cause me to be infected.I understand that I have the option to defer my treatment to a later date. However, I agree to proceed with my desired treatment at this time.I confirm I am not experiencing any of the following symptoms of COVID-19 (i.e. shortness of breath, loss of taste or smell, dry cough, runny nose, sore throat, flu, fever, headache)I declare that I have NOT in the past 14 days traveled outside of the country or domestically by commercial transportation by air, land, or sea.I understand the inherent risk of becoming infected with COVID-19 by simply visiting clinics or facilities. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this method of treatment.I give my express permission to this facility and the staff in providing healthcare for my benefit.
I have read, or have read to me the above COVID-19 informed consent to treat information. I understand that it is not possible to completely eliminate the risk of infection from COVID-19. I have had the opportunity to ask questions which were answered to my satisfaction.
By signing this form, I declare that I am of legal age or I am represented by a guardian or representative who is of legal age, and I give my full consent with a full understanding of the risks and benefits associated with the treatment during this pandemic.
Name of Patient
First NameLast Name
Signature
Clear
Name of Legal Guardian/Representative
First NameLast Name
Signature
Clear
Should be Empty: