Consent For Treatment Covid-19 Addendum - Penn Medicine Becker ENT & Allergy

CONSENT FOR TREATMENT – COVID-19 ADDENDUM
The patient understands that COVID-19 is an infectious disease that can cause injury and death. The patient may contract COVID-19 (a) by breathing in droplets and/or aerosols that are produced when an infected person breaths, coughs or sneezes, (b) when an infected person, with or without symptoms, spreads COVID-19 by touching a surface, and/or (c) through other ways that may become known or apparent before or after the Office Visit.

The patient understands that their IN-OFFICE TREATMENT is elective in nature. The patient understands that all healthcare workers involved in their care are taking strict safety precautions to protect both the patient and themselves. The precautions that are being undertaken by the healthcare providers have been explained to the patient in detail. The patient understands that there is a risk of infection with COVID-19 despite these precautions.

The patient understands that – while all are at risk – people who are over 60 and people with chronic medical conditions, including but not limited to cardiovascular disease, high blood pressure, diabetes and lung disease, appear to be more likely to have severe disease or death from COVID-19. If the patient is at higher risk, they indicate that they have given special consideration as to whether their problem warrants leaving their homes at this time to come to the office. They have weighed the degree to which they need to be seen with the increasing risk of serious consequences in contracting COVID-19.

I HAVE REVIEWED THE ABOVE AND VOLUNTARILY INDICATE MY CONSENT FOR THIS AND FUTURE OFFICE VISIT(S) (AT PENN MEDICINE BECKER ENT) INCLUDING POSSIBLE NASAL ENDOSCOPY, FLEXIBLE NASOPHARYNGOLARYNGOSCOPY, SINUS CULTURE, CERUMEN REMOVAL, ALLERGY TESTING, ALLERGY SHOT, AUDIOLOGY EVALUATION AND TREATMENT, AND OTHER PROCEDURES THAT MAY BE DISCUSSED AND AGREED TO BY ME.

I UNDERSTAND AND AGREE THAT THIS CONSENT IS APPLICABLE FOR ANY AND ALL VISITS AT PENN MEDICINE BECKER ENT CONDUCTED WITHIN 1 YEAR OF THE SIGNING DATE BELOW.
Patient Name (Print)*
Email*
Patient Signature*
Date*
MM slash DD slash YYYY
Patient Guardian (if patient is under 18 years old, or otherwise with guardian):
Print name
Signature
Date
MM slash DD slash YYYY
By submitting this form I agree to the Terms of Use
Phone
This field is for validation purposes and should be left unchanged.

CONSENT FOR TREATMENT – COVID-19 ADDENDUM