INFORMED CONSENT Covid-19 risk
I understand that I am opting for an in-person consultation and/or treatment/procedure.
I also understand that the novel corona virus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize Jennifer Chen and all the staﬀ at South Pasadena smiles are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this elective treatment/procedure. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/procedure, and I give my express permission for Dr. Jennifer Chen and all the staﬀ at South Pasadena Smiles to proceed with the same. I understand my cooperation is mandatory, whether or not I personally feel such COVID-19 procedures and/or preventive measures are necessary.
I understand that, even if I have been tested for COVID-19 and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID-19 after the test. I understand that, if I have a COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this elective treatment/procedure/surgery can lead to a higher chance of complication and death. I have informed any COVID-19 testing I or any person living with me during the past 14 days has received, as well as the results of that testing, and if I am tested between now and the date of my procedure, I will immediately provide the results of that testing to Jennifer Chen DDS. I understand Dr Jennifer Chen may require that I be tested, possibly at my own expense and regardless of any prior testing, and that the results of that testing must be satisfactory to Jennifer Chen DDS, before I may receive my procedure.
I understand that possible exposure to COVID-19 before/during/after my treatment/procedure 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, other potential complications, and the risk of death. In addition, after my treatment/procedure, I may need additional care that may require me to go to an emergency room or a hospital.
I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the treatment/procedure itself.
I have been given the option to defer my in-person consultation and/or treatment/procedure to a later date. However, I understand all the potential risks, including but not limited to the potential
short-term and long-term complications related to COVID-19, and I would like to proceed with my desired in person consultation and/or treatment/procedure.
I am instructed to provide COVID-19 test result prior to treatment/procedure/surgery. After having the test, I am instructed to stay home/self quarantine until the date of surgery. I understand that if the test result is positive even though I am asymptomatic, the treatment/procedure will be postponed until I provide negative COVID-19 test result. After surgery, I will also practice social distancing and safety practice and will have only persons who have been in contact with me prior to surgery to assist me in the postoperative care to reduce any exposure to COVID-19.
Jennifer Chen DDS 1928 Huntington Drive South Pasadena CA 91030
I AM SATISFIED WITH THE EXPLANATION PROVIDED AND AGREE TO PROCEED.