COVID-19 Patient Consent for Treatment

COVID-19 Patient Consent for Treatment
Protocols to follow for COVID for In-person Appointments
1. Wait in your car until 5 minutes before your appointment.
2. If scheduled at our Duncan location in Central West End, please enter the main back entrance (on Duncan Ave side of building). Here you will be temperature screened and must wear mask.
3. Wait inside main hospital lobby until told to come back to Dr. Patel's office lobby.
4. Only you as the patient can come back (no family permitted at this time). Family can wait in the main hospital lobby with you if desired.
5. At this second lobby, you will sign any needed consent forms, pay any applicable copay, and Dr. Patel will bring you to the exam room for your visit.
6. We thank you for your cooperation to help keep everyone safe at this time! Fortunately, Dr. Patel is fully vaccinated at this time.
Risk Disclosure for the Pain Management Procedures During the COVID-19 Pandemic
Signature:*

Clear
Are you the patient?*

YesNo
If you are signing for the patient, please answer the following:*

I am permitted to sign for the patient as I am their legal guardian/medical power of attorney/decision maker.
My name is First Name* Last Name* and my relationship to the patient is blank*.
Patient's Name:*

First NameLast Name
Patient's Date of Birth (MM-DD-YYYY):
Should be Empty: