Covid-19 Informed Consent for In-Person Physical Therapy or Dance Injury Prevention Screening Services

Covid-19 Informed Consent for In-Person Physical Therapy or Dance Injury Prevention Screening Services

By submitting this form, you agree to have services for you or your child performed face-to-face in your home environment or office space during the pandemic.
Patient Information*

First NameLast Name
Date of Birth*

MonthDayYear
This document contains important information about your decision to participate in in-person physical therapy or dance injury prevention screening services for you or your child provided in your home environment or dance studio.
Decision to Meet Face-to-Face

We have agreed to meet in person for you or your child's physical therapy or dance injury prevention screening services in your home environment. However, I may require that we meet via telehealth if there is a resurgence of the pandemic, or if other health concerns arise. If you have concerns about meeting through telehealth, we will talk about it first and try to address any issues. You understand that I may determine that we transition or return to telehealth for everyone’s well-being if I believe it is necessary.

If you decide at any time that you would feel safer staying with, or returning to, telehealth services, I will respect that decision, as long as it is feasible and clinically appropriate.
Risks of Exposure

I understand the coronavirus causes the disease known as COVID-19. I understand the coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

I understand in-person services may increase the risk of my family's, including myself, exposure to COVID-19 despite my own and therapist's precautions. I am aware that exposure to COVID-19 can result in severe illness, intensive therapies, extended intubation and/or ventilator support, life-altering changes to my health, and even death.
Your Responsibilities

To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, and our families) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting/returning to a telehealth arrangement.
- You will only keep in-person appointment if every resident in your household is symptom free.
- You will be responsible for taking you or your child's temperature prior to therapist coming to your home on a scheduled visit. If it is higher than 100.4, or if your child has other symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth.
- You will wash you and your child's hands and/or use hand sanitizer upon therapist entering the home.
- If a resident of your household tests positive for the coronavirus/COVID-19, you will immediately let the therapist know and we will have sessions via telehealth until it is safe to return to in-person visits.
The above precautions may change if additional local, state or federal orders or guidelines are published. In this event, we will discuss any necessary changes.
Therapist's Responsibilities
- Therapist will only keep in-person appointment if symptom free.
- Therapist will sanitize hands prior to entering your home and will wash hands and/or use hand sanitizer prior to beginning session with you or your child.
- Therapist will immediately notify you if she or any family member residing in her home test positive for the coronavirus/COVID-19 so that you can take appropriate precautions.
- Therapist will disinfect any therapy supplies deemed necessary to bring in the home.
- Therapist will wear a mask or face covering while in your home.
All topics above have been discussed with me, and all my questions have been answered to my satisfaction. Being fully informed:*

I acknowledge the contagious nature of the coronavirus/COVID-19 and the CDC still recommend practicing social distancing.I understand that anyone in my household including my child has a risk of being exposed to the coronavirus and become infected with COVID-19 during physical therapy sessions or dance injury prevention screening.I accept the risk of COVID-19 exposure and I will be responsible for any cost associated with COVID-19 diagnostic test and treatment.I acknowledge that the risk of becoming exposed and/or infected with the coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others including but not limited to my and the therapist's family members.I agree to obey the rules of C the Movement, LLC practice during my or my child's appointment in order to minimize the spread of viruses.
By signing below, I confirm that I understand and agree to all terms, conditions, and statements in this form.
Parent/Guardian Name (if applicable)*

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Date*

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Client/Parent/Guardian Signature*

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