COVID face to face office visit consent

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, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service.

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.

  • You will only keep your in-person appointment if you are symptom free.
  • You will complete the COVID screening questionnaire available on my website before every face to face visit. I ask that this is completed within an hour of your scheduled appointment.
  • 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 or proceed using telehealth.  
  • You will wash your hands or use alcohol-based hand sanitizer when you enter the building. 
  • You will adhere to the safe distancing precautions we have set up in the waiting room and therapy room (staying 6ft from others).
  • You will keep a distance of 6 feet and there will be no physical contact with me.
  • You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands. 
  • You will not bring other members of your household with you to the appointment. I no longer have a waiting room, to allow for social distancing, and minimizing risk. If you are unable for example, to obtain child care, please notify me immediately, so we can potentially adjust the appointment to Telehealth.
  • 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 know and we will then [begin] resume treatment via telehealth. I will in exchange, do the same.

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. 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, and all of our families 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 I test positive for the coronavirus, I will notify you so that you can take appropriate precautions. 

Informed Consent

This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together.

Your signature below shows that you agree to these terms and conditions. 

Office Safety Precautions in Effect During the Pandemic

My office is taking the following precautions to protect my patients and help slow the spread of the coronavirus.

  • I am fully vaccinated against the COVID-19 virus. While I cannot require my patients to be vaccinated, it is strongly encouraged. 
  • You will complete the COVID screening questionnaire available on my website before every face to face appointment. If you are experiencing any symptom(s), I reserve the right to change the appointment to Telehealth immediately. 
  • Mask is worn (at least ) upon entering the building and upon entry into my office. We will discuss once you arrive,  if you feel more comfortable with us wearing them or not.
  • My furniture has been rearranged from Pre-Pandemic times to be 6 feet apart.
  • Restroom soap dispensers are maintained and everyone is encouraged to wash their hands.
  • Hand sanitizer that contains at least 60% alcohol is available upon entry into my office.
  • I schedule appointments at specific intervals to allow for 1 person at a time. 
  • My waiting room from pre-pandemic times has been removed. If someone provides transportation to your appointment they will need to return within standard 50 minutes , or wait in their car. I no longer have the space for others to wait during your appointment. It is strictly following one appointment at a time procedures.
  • I ask that you kindly text me at 248-840-5517 upon arrival when in your vehicle. I will return the text, when you are able to come into my office. Please do not wait outside my office door. The door will be locked, and if it is locked it means I am in session with a prior patient. I need time in between to clean and sanitize.
  • I continue to use Square for co pays, deductible payments, and cash payments. There is no need for the exchange of cards between us. If there is, sanitizer is available for sanitizing cards, pens, etc.
  • Physical contact is not permitted.
  • Tissues and trash bins are easily accessed. Trash is disposed of on a frequent basis.
  • The therapy room is thoroughly sanitized throughout the day.