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.
I have had an opportunity to ask questions and all my questions have been answered to my satisfaction. I have been given the option to defer my treatment/procedure/surgery to a later date. However, I hereby acknowledge and assume all the potential risks, including but not limited to the risk of infection with COVID-19 and the potential short-term and long-term complications related to COVID-19, including death, and I give my express permission for ________________________________________ (provider name) and all the staff at ________________________________________ (facility name) to proceed with my desired treatment/procedure/surgery. __________________________________________________________________________ Patient Signature __________________________________________________________________________ Patient Name _____________________________________ Date Click here to download this form as a PDF

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