
COVID-19 Consent for Treatment/Procedure/Surgery
COVID-19 CONSENT FOR TREATMENT/PROCEDURE/SURGERY
I _____________________________________ (patient name) am opting for a treatment/procedure/surgery that is not urgent or an emergency. In giving my consent for the treatment/procedure/surgery, I hereby affirm that I understand the following:
- The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization.
- Individuals can unknowingly transmit COVID-19 without displaying any symptoms.
- It is impossible to determine with certainty who is infected with COVID-19 and who is not given the current limits of testing.
- COVID-19 tests may fail to detect the virus and those who have received a negative test result may have the virus or may have contracted the virus after being tested.
- COVID-19 is extremely contagious and is believed to spread by contact with respiratory droplets from infected persons either directly or through contact with surfaces around those infected.
- As a result, Federal and State health agencies have recommended social distancing.
- There is an increased risk of becoming infected with COVID-19 not only by virtue of proceeding with this treatment/procedure/surgery but also by virtue of being present in the Hospital during the pandemic.
- If I have a COVID-19 infection, even if I do not have any symptoms for the same, proceeding with this treatment/procedure/surgery can lead to a higher chance of complications including death.
- Specifically, possible exposure to COVID-19 before/during/after my treatment/procedure/surgery may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, intensive care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, the need for additional medical care and/or hospitalization, other potential complications, and death.
- Because the nature of the virus is not yet completely understood, the increased risk associated with the treatment/procedure/surgery cannot yet be quantified and there may be additional risks, which may not currently be known at this time.
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