COVID-19 Informed Consent To Treat -

i understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand knowledge on COVID-19 is still evolving.

I understand that I am the decision maker for my health care. Part of this office’s role is to provide me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.

To proceed with receiving care, I confirm and understand the following (initial in all seven places provided).

I understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-to-person contact, in which COVID-19 can be transmitted. * I understand that if I am opting for an In-office visit and treatment that may not be urgent, that I have the option to defer my treatment to a later date or be seen by televisit. HOwever while I understand the potential risks associated with being seen in the office and/or receiving treatment during the COVID-19 pandemic, I agree to proceed with my desired visit/treatments at this time. * I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of treatments, I may have an elevated risk of contracting COVID-19 simply by being in a health care office. * I confirm I am not experiencing any of the following symptoms of COVID-19 that are listed below:
*fever *Dry Cough *sore throat
*Shortness of breath *Runny nose *Loss of taste or smell
*exposure to someone with +COVID testing in the last 14 days * I understand travel increases my risk of contracting and transmitting the COVID-19 virus. I verify that I have not traveled in the past 14 days: 1. OUtside of the United States to countries that have been affected by COVID-19; or 2. Domestically within the United States by commercial airline, bus, or train. * I am informed that the providers and staff at Rheumatology Center Of Houston have implemented preventative measures intended to reduce the spread of COVID-19. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected with COVID-19 by proceeding with this visit/treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this visit and give my permission to the providers and staff at rheumatology center of houston to proceed with providing care. * I have been offered a copy of this consent form. * I knowingly and willingly consent to the office visit/treatment with the full understanding and disclosure of the risks associated with receiving care during the COVID-19 pandemic. I confirm all of my questions were answered to my satisfaction and I have been offered alternatives to office visit and treatments.

I have read, or have had read to me, the above COVID-19 informed consent to treat in the office. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive care as is deemed appropriate for my circumstances. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek care from this office. I understand I can revoke this consent anytime with a written notice to the office.

Patient/parent/guardian Signature: * Date * Witness signature: Date