INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS
This document contains important information about our decision (yours and ours) to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let us know if you have any questions. When you sign this document, it will be an official agreement between us.
Your Responsibility to Minimise Your Exposure
To obtain services in person, you agree to take certain precautions which will help keep everyone (you, us, and our families, other staff and other patients safer from exposure and sickness.
Please read the following carefully and sign in the form below to indicate that you understand and agree to these actions:
You will only keep your in-person appointment if you are symptom free.
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 cancel the appointment. If you wish to cancel for this reason, you won’t be charged our normal cancellation fee.
You will wait in your car or outside until no earlier than 5 minutes before our appointment time. If you choose to wait in the waiting area, please wear a face mask.
You will wash your hands or use alcohol-based hand sanitizer when you enter the clinic.
You will adhere to the safe distancing precautions we have set up in the waiting room and therapy room. For example, you won’t move chairs or sit where we have signs asking you not to sit.
You will wear a mask in all areas of the office.
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 us know.
If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let us know.
If a resident of your home tests positive for the infection, you will immediately let us know.
We 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.
Our Commitment to Minimise Exposure
Our practice has taken steps to reduce the risk of spreading the coronavirus within the office. Please let us know if you have questions about these efforts.
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.
If You or any of our staff Are Sick
You understand that we are committed to keeping you, our staff and all of our families safe from the spread of this virus. If you show up for an appointment and we believe that you have a fever or other symptoms, or believe you have been exposed, we will have to stop the session immediately and advise to follow the self-isolation guidelines, as well as contacting the NHS COVID-19 helpline.
If any of our staff test positive for the coronavirus, we will notify you so that you can take appropriate precautions.
Your Confidentiality in the Case of Infection
If you have tested positive for the coronavirus, we may be required to notify local health authorities that you have been in the office. If we have to report this, we 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. By signing this form, you are agreeing that we may do so without an additional signed release.