Patient Name: *

First Name

Last Name

Date: *

MM

DD

YYYY

Please answer the following questions. Check all boxes that apply:

Exposure to person with a case of COVID-19 within the past 14 days

In the last 14 days, have you experienced:

*If you check any of the below and the symptoms cannot be attributed to another health condition, unfortunately I cannot treat you at this time. I’m happy to offer you an online consultation, and/or refer you to an appropriate facility.

New Fever

New cough, shortness of breath, or difficulty breathing

New loss of sense of smell or change in taste

New changes in skin (rash, skin discoloration, discoloration of toes

New chills, feeling cold, or shivering

New headache

New fatigue

Sore throat

Nausea/vomiting

Diarrhea

New nasal congestion or runny nose

New body or muscle aches that are not caused by a specific activity or injury

While on the Mudras premises, I agree to: *

Maintain a distance of six (6) feet from other persons whenever possible.

Wear a face mask.

Wash my hands for 20 seconds when entering the office.

To practice proper cough & sneeze etiquette by coughing/sneezing into my elbow, and to give warning to others if I am about to cough or sneeze, so that they can maintain a safe distance.

Remain in areas designated for my visit.

Proceed with receiving care: *

I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that I am the decision maker for my health care. Part of this office’s role is to provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult. To proceed with receiving care, I confirm and understand the following (mark all seven checkboxes provided)

I understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-to- person contact, in which COVID-19 can be transmitted.

I understand that I am opting for an elective treatment that may not be urgent or medically necessary. I understand there are alternatives to receiving this care, which could including receiving care from another type of provider, or postponing care altogether at this time. However, while I understand the potential risks associated with receiving treatment during the COVID-19 pandemic, I agree to proceed with my desired treatment at this time.

I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of procedures, I may have an elevated risk of contracting COVID-19 simply by being in a health care office.

I confirm I am not experiencing any of the following symptoms of COVID-19 that are listed here: (Fever, Shortness of Breath, Dry Cough, Runny Nose, Sore Throat, Loss of Taste or Smell)

I understand that travel increases my risk of contracting and transmitting the COVID-19 virus. I verify that in the past 14 days, I have NOT traveled outside of the United States to countries that have been affected by COVID- 19.

I am informed that you and your staff have implemented preventative measures intended to reduce the spread of COVID-19. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected with COVID-19 by proceeding with this treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment and give my express permission to you and the staff at your offices to proceed with providing care.

I will be offered a copy of this consent form.

Signed *

I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION. I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FROM ALL PROVIDERS IN THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE. I acknowledge that the information above is correct:

First Name

Last Name

Date Signed *

MM

DD

YYYY