Informed Consent for In-Person Services During the COVID-19 Public Health Crisis

This document contains important information about our decision (yours and mine) 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.

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, 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 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.
• If you have been in contact with someone who has tested positive within the last 5 days, you will notify me and either reschedule or change to a telehealth session.
• You will wash your hands or use alcohol-based hand sanitizer when you enter the building.
• You will wear a mask in the waiting area.
• You will take steps between appointments to minimize your exposure to COVID.
• 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 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. Let me know if you have any questions about our protocol.

If You or I Are Sick
You and I agree to keep ourselves safe from the spread of this virus as much as we can. You will not show up for an appointment with a fever or other symptoms, or if you believe you have been exposed. We can follow up with services by telehealth as appropriate. If I test positive for the coronavirus, I will notify you immediately so that we can take appropriate precaution

Informed Consent
‍This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together.  By checking below shows that you agree to these terms and conditions.

Office Safety Precautions in Effect During the Pandemic  
My practice has taken steps to reduce the risk of spreading the coronavirus within the office.

• Office seating in the waiting room and in therapy/testing rooms has been arranged for appropriate physical distancing.
• Restroom soap dispensers are maintained and everyone is encouraged to wash their hands.
• Hand sanitizer that contains at least 60% alcohol is available in the the waiting room.
• I schedule appointments at specific intervals to minimize the number of people in the waiting room.
• Tissues and trash bins are easily accessed. Trash is disposed of on a frequent basis.
• Try to arrive no more than 5 minutes prior to your appointment time.