INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS
This document contains important information about our decision (yours and mine) to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let me know if you have any questions. When you sign this document, it will be an official agreement between us.
Decision to Meet Face-to-Face
We have agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, I may require that we meet via telehealth. If you have concerns about meeting through telehealth, we will talk about it first and try to address any issues. You understand that, if I believe it is necessary, I may determine that we return to telehealth for everyone’s well-being.
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. Reimbursement for telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue we may also need to discuss.
Risks of Opting for In-Person Services
You understand that by coming to the office or any public venue you are assuming the risk of exposure to the corona virus or other public health risk.
Your Responsibility to Minimize Your Exposure
To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, and our families, and other patients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our returning to a telehealth arrangement.
Initial each to indicate that you understand and agree to these actions:
You will only keep your in-person appointment if you are symptom free.
You will take your temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment and proceed using telehealth.
You will wait in your car until I text you to enter the office.
You will wash your hands or use alcohol-based hand sanitizer when you enter the building.
You may wear a mask in all areas of the office.
You understand I will not be wearing a mask.
You will keep a distance of 6 feet and there will be no physical contact with me. (no shaking hands, hugging, etc.)
You will keep all family members at home unless they are part of the appointment. If your child is a participant of your appointment, you will make sure that your child follows all of these sanitation and distancing protocols.
You will take steps between appointments to minimize your exposure to COVID.
If you have a job that exposes you to other people who are infected, you will immediately let me know.
If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let me know.
If you have been on a train, plane or cruise ship within 14 days of your appointment, you agree to do telehealth.
If you have attended a large venue (wedding, concert, sports event, etc.) within 14 days of your appointment you agree to do telehealth.
If you have been exposed to any person who has tested positive for the infection, you will immediately let me know and we will resume treatment via telehealth.
I may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.
My Commitment to Minimize Exposure
My practice has taken steps to reduce the risk of spreading the coronavirus within the office and we have posted our efforts on our website and in the office. Please let me know if you have questions about these efforts.
If You or I Are Sick
You understand that I am committed to keeping you, me, our families and my clients safe from the spread of this virus. If you show up for an appointment and I believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate.
If you or I test positive for the coronavirus we agree to notify each other immediately so we may take appropriate precautions.
Your Confidentiality in the Case of Infection
If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release.
This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together.
Office Safety Precautions in Effect During the Pandemic
• My office is taking the following precautions to protect our patients and help slow the spread of the coronavirus.
• Office seating in the waiting room and in therapy room has been arranged for appropriate physical distancing.
• I maintain safe distancing.
• Restroom soap dispensers are maintained and everyone is encouraged to wash their hands.
• Hand sanitizer that contains at least 60% alcohol is available in the lobby and therapy room.
• We schedule appointments at specific intervals to minimize the number of people in the office.
• We ask all patients to wait in their cars until I text you to enter the building.
• Door handles, tables, chairs, pens and other areas that are commonly touched are thoroughly sanitized after each use.
• Physical contact is not permitted.
• Tissues and trash bins are easily accessed. Trash is disposed of on a frequent basis.
• Common areas are thoroughly disinfected at the end of each day.