INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19

Important information and polocies 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 form, it will be an official agreement between us.

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 starting / returning to a telehealth arrangement.

  • Please 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 or proceed using telehealth. 

  • When you arrive please wait in your car or outside until no earlier than 5 minutes before our appointment time.

  • I will provide an alcohol-based hand sanitizer for you to use when entering the building.

  • You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) with me.

  • If you are bringing your child, you will make sure that your child follows all of these sanitation and distancing protocols.

  • 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 a resident of your home tests positive for the infection, you will immediately let me [and my staff] know and we will then [begin] resume treatment via telehealth.

Thanks for submitting!