INFORMED CONSENT FOR IN-PERSON SERVICES DURING THE COVID-19 PUBLIC HEALTH CRISIS

This document contains important information about our decision to begin/resume in-person services in light of the COVID-19 public health crisis. Our decision is based in part on recommendations by the Center for Disease Control (CDC), but other factors may be considered. Some of these include but are not limited to: whether we and our families have been vaccinated, our health or the health of those we are in close contact with, and risk of exposure outside of this setting. There may be other concerns that we can talk about.  I  am  utilizing Pima County’s COVID-19 Progress Report and Local Recommendations as a guide.  If key indicators show “critera not met”, I will likely return to telehealth. (link below).

https://webcms.pima.gov/cms/One.aspx?portalId=169&pageId=568644

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 is also determined by the insurance companies and applicable law, so we’ll discuss any financial implications if needed. 

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, [other staff] 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 tell me if you’ve been vaccinated. If you haven’t, we’ll talk about the reasons and whether it’s possible to meet safely in person.
• You will only keep your in-person appointment if you are symptom free.
• You will only keep your in-person appointment if you have been fever free for a minimum of 10 days prior to our appointment.
• You will cancel your appointment if you have been in contact with someone who has tested positive within the last 14 days.
• 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.  If you wish to cancel for this reason, I won’t charge you our normal cancellation fee. ___
• You will wait in your car or outside [or in a designated safer waiting area] until no earlier than 5 minutes before our appointment time.
• You will wear a mask in the waiting room. 
• You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) with me [or staff].
• 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 [and my staff] 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.

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.  I will remain up to date on vaccines.