COVID-19 Agreement Form

I {pleaseEnter} understand that I am opting for an elective medical consultation/treatment/procedure.

I understand that the novel coronavirus, the World Health Organization has declared COVID-19, a worldwide pandemic and that COVID-19 is extremely contagious and is believed to spread by person- to-person contact; and, as a result, social distancing is recommended. This is not entirely possible with my proposed treatment, however, I am satisfied that safety measures are in place to minimise risk as much as possible, and patient contact will be kept to an absolute minimum in line with medical need.

Initials *

I understand the Management and Clinical Staff are closely monitoring the COVID-19 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 treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective consultation/medical treatment/procedure, and I give my express permission to proceed.

Initials *

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I understand that COVID-19 can cause additional health risks, some of which may not currently be known at this time, in addition to those risks associated with the medical consultation/ treatment/procedure itself.

Initials *

I have been given the option to defer my medical consultation/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 medical treatment/procedure.

Initials *

I confirm that I am not presenting with any of the following symptoms of COVOID-19 listed below:

• Fever
• Shortness of Breath
• Loss of Sense of Taste or Smell • Dry Cough
• Runny Nose
• Sore Throat

Initials *

I understand that air travel significantly increases my risk of contracting and transmitting the COVID- 19 virus. I confirm that I have not travelled in the past 15 days

Initials *

I confirm that if I develop COVID-19 symptoms following my medical consultation/treatment/procedure or a known contact of mine develops symptoms, I will immediately inform the practitioner to enable appropriate measures to be put in place and contact tracing to commence

Initials *

Patient Name: {pleaseEnter}

Signature

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Date