I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further
understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long
incubation period during which carriers of the virus may not show symptoms and still be contagious.
I understand that I am the decision maker for my health care. Part of this office’s role is to provide me with information to assist me
in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement
regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the
current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.
To proceed with receiving care, I confirm and understand the following (Initial in all seven places provided) Initial
I understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-toperson contact, in which COVID-19 can be transmitted.
I understand that I am opting for an elective treatment that may not be urgent or medically necessary, and that I
have the option to defer my treatment to a later date. However, while I understand the potential risks associated
with receiving treatment during the COVID-19 pandemic, I agree to proceed with my desired treatment at this time.
I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics
of procedures, I may have an elevated risk of contracting COVID-19 simply by being in a health care office.
I confirm I am not experiencing any of the following symptoms of COVID-19 that are listed below:
*Shortness of Breath
*Loss of Taste or Smell
I understand travel increases my risk of contracting and transmitting the COVID-19 virus. I verify that I have NOT in
the past 14 days I have not traveled: 1) Outside of the United States to countries that have been affected by
COVID-19; or 2) Domestically within the United States by commercial airline, bus, or train.
I am informed that you and your staff have implemented preventative measures intended to reduce the spread of
COVID-19. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected
with COVID-19 by proceeding with this treatment. I hereby acknowledge and assume the risk of becoming infected
with COVID-19 through this elective treatment and give my express permission to you and the staff at your offices to
proceed with providing care.
I have been offered a copy of this consent form.
I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS
ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY
I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT
POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT
ITS CONTENT, AND BY SIGNING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED
APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FROM ALL PROVIDERS IN
THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE.