Dermatology Partners

Consent to Treatment During Covid-19 Pandemic

Consent to Treatment During Covid-19 Pandemic

I understand that I am opting for a medical/surgical/cosmetic treatment or procedure that may not be urgent nor medically necessary.

I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that the doctors, providers, and staff  at Dermatology Partners, Inc. are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this medical/surgical/cosmetic appointment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this office visit and I give my express permission to proceed with my medical/surgical/cosmetic treatment.

I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that, if I have a COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this office visit can lead to a higher chance of complication and death. I understand that possible exposure to COVID-19 before/during/after my office visit may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death. In addition, after my office visit, I may need additional care that may require me to go to an emergency room or a hospital.

I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the treatment/procedure/surgery itself.

I have been given the option to defer my treatment/procedure/surgery to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired treatment/procedure/surgery.




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Signature Certificate
Document name: Consent to Treatment During Covid-19 Pandemic
lock iconUnique Document ID: 5b6cf6cbaed3bfcbcc17af8325b8e1b2470c5bed
Timestamp Audit
May 7, 2020 1:56 pm MSTConsent to Treatment During Covid-19 Pandemic Uploaded by Dermatology Partners Inc - IP