Patient Advisory and Acknowledgement Receiving Medical Treatment During the COVID-19 Pandemic

COVID-19 is an infectious disease caused by a newly discovered coronavirus and there is limited information regarding risk factors for this severe disease. The disease causes respiratory illness (like the flu) with symptoms such as a cough, fever, and in more severe cases, difficulty breathing. It may also present as a gastrointestinal, neurological, kidney, blood clotting, and myocardial conditions. COVID-19 is primarily spread through close personal contact or airborne droplets – coughing or sneezing. People may also contract the illness if they touch a surface infected with COVID-19 and then touch their mouths, noses or eyes. Some cases have been reported of contraction through aerosol propulsion associated with talking and breathing. There’s currently no vaccine to prevent COVID-19, nor effective medications to reverse it.

While our office complies with State Health Department and the Center for Disease Control and Prevention infection control (CDC) guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

Our Staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other person (including other patients) could be infected with or without their knowledge.

According to the CDC, older adults and people of any age who have serious underlying medical conditions might be at higher risk for severe illness from COVID-19.

• Those at high-risk for severe illness from COVID-19 are:
• People 65 years and older
• People who live in a nursing home or long-term care facility People of all ages with underlying medical conditions, particularly if not well controlled, including:
• People with chronic lung disease or moderate to severe asthma
• People who have serious heart conditions
• People who are immunocompromised o Many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications
• People with severe obesity (body mass index [BMI] of 40 or higher)
• People with diabetes
• People with chronic kidney disease undergoing dialysis
• People with liver disease
• People with underlying neurological conditions
• People with high blood pressure

I understand that it is ultimately my decision as to whether I proceed with today’s exam/procedure now or to wait until after COVID-19 is less prevalent. I further understand that family, caregivers and visitors will be limited and that I will be required to wear a mask during my appointment, check my temperature and will practice physical distancing in an effort to reduce the spread of COVID-19 infection. In the event that I experience symptoms of COVID19 after my scheduled office visit, I understand that there is a significant chance that I may have already been exposed to the Covid-19 virus in the week or two before my appointment and that I consented to the risks of exposure during my visit via office or during my commute to my appointment. In addition, I will immediately notify the office of such symptoms or positive testing of the virus.

I have read and discussed with my personal physician and my physiatrist the risks of proceeding with the procedure/examination versus the risks associated with delaying the procedure/examination. I have decided to proceed with the procedure/examination. I understand that I accept full responsibility for any consequences of that decision. I agree that Rehabilitation Associates of Colorado, P.C. and its physicians, will not be held responsible or legally liable for my decision or any future consequences of my decision as long as they are acting in good faith.

By signing below, I confirm that I have read, or have had read to me, and understand the above information. I am of sound mind, under no undue influence and am competent to make this decision and do so of my own free will.