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COVID-19 RISK INFORMED CONSENT

I understand that I am opting for an elective treatment/procedure/surgery that is not urgent and may not be 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 Dr. Paul Cox and all the staff at WIFH 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 elective treatment/procedure/surgery. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/procedure/surgery, and I give my express permission for Dr. Cox and all the staff at WIFH to proceed with the same.

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 elective treatment/procedure/surgery can lead to a higher chance of complication and death.

I understand that possible exposure to COVID-19 before/during/after my treatment/procedure/surgery 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 elective treatment/procedure/surgery, 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.

I UNDERSTAND THE ABOVE EXPLANATION AND HAVE NO ADDITIONAL QUESTIONS. I CONSENT TO THE PROCEDURE

Today's Date: January 19, 2021

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Your health and safety are our number one priority. In order to ensure your safety and the safety of others at WIFH, we are asking all patients to answer a few brief questions regarding possible symptoms and exposure to COVID-19.

Thank you for helping us to maintain a healthy and safe environment. 

Do you have a fever?*
No
Yes
Do you have a cough?*
No
Yes
Do you currently have symptoms of a lower respiratory illness (e.g. cough or shortness of breath)?*
No
Yes
Please check if you are experiencing any of the following symptoms below which may be associated with COVID-19?
Runny nose/congestion
Sore Throat
Loss of sense of smell or taste
Headache Diarrhea
Rash/Skin irritation
Muscle pain/weakness
Nausea/Vomiting
Unexplained bleeding/bruising
Have you had a fever or cough in the last 7 days?*
No
Yes
Have you been in close contact with anyone who has any of the above symptoms in the last 14 days?*
No
Yes
Have you been in close contact with anyone who has been diagnosed with COVID -19 in the last 30 days?*
No
Yes
Have you travelled outside of Georgia in the last 30 days?*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Your health and safety are our number one priority. In order to ensure your safety and the safety of others at WIFH, we are asking all patients to answer a few brief questions regarding possible symptoms and exposure to COVID-19.

Thank you for helping us to maintain a healthy and safe environment. 

Do you have a fever?*
No
Yes
Do you have a cough?*
No
Yes
Do you currently have symptoms of a lower respiratory illness (e.g. cough or shortness of breath)?*
No
Yes
Please check if you are experiencing any of the following symptoms below which may be associated with COVID-19?
Runny nose/congestion
Sore Throat
Loss of sense of smell or taste
Headache Diarrhea
Rash/Skin irritation
Muscle pain/weakness
Nausea/Vomiting
Unexplained bleeding/bruising
Have you had a fever or cough in the last 7 days?*
No
Yes
Have you been in close contact with anyone who has any of the above symptoms in the last 14 days?*
No
Yes
Have you been in close contact with anyone who has been diagnosed with COVID -19 in the last 30 days?*
No
Yes
Have you travelled outside of Georgia in the last 30 days?*
No
Yes
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Your health and safety are our number one priority. In order to ensure your safety and the safety of others at WIFH, we are asking all patients to answer a few brief questions regarding possible symptoms and exposure to COVID-19.

Thank you for helping us to maintain a healthy and safe environment. 

Do you have a fever?*
No
Yes
Do you have a cough?*
No
Yes
Do you currently have symptoms of a lower respiratory illness (e.g. cough or shortness of breath)?*
No
Yes
Please check if you are experiencing any of the following symptoms below which may be associated with COVID-19?
Runny nose/congestion
Sore Throat
Loss of sense of smell or taste
Headache Diarrhea
Rash/Skin irritation
Muscle pain/weakness
Nausea/Vomiting
Unexplained bleeding/bruising
Have you had a fever or cough in the last 7 days?*
No
Yes
Have you been in close contact with anyone who has any of the above symptoms in the last 14 days?*
No
Yes
Have you been in close contact with anyone who has been diagnosed with COVID -19 in the last 30 days?*
No
Yes
Have you travelled outside of Georgia in the last 30 days?*
No
Yes
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Your health and safety are our number one priority. In order to ensure your safety and the safety of others at WIFH, we are asking all patients to answer a few brief questions regarding possible symptoms and exposure to COVID-19.

Thank you for helping us to maintain a healthy and safe environment. 

Do you have a fever?*
No
Yes
Do you have a cough?*
No
Yes
Do you currently have symptoms of a lower respiratory illness (e.g. cough or shortness of breath)?*
No
Yes
Please check if you are experiencing any of the following symptoms below which may be associated with COVID-19?
Runny nose/congestion
Sore Throat
Loss of sense of smell or taste
Headache Diarrhea
Rash/Skin irritation
Muscle pain/weakness
Nausea/Vomiting
Unexplained bleeding/bruising
Have you had a fever or cough in the last 7 days?*
No
Yes
Have you been in close contact with anyone who has any of the above symptoms in the last 14 days?*
No
Yes
Have you been in close contact with anyone who has been diagnosed with COVID -19 in the last 30 days?*
No
Yes
Have you travelled outside of Georgia in the last 30 days?*
No
Yes
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Your health and safety are our number one priority. In order to ensure your safety and the safety of others at WIFH, we are asking all patients to answer a few brief questions regarding possible symptoms and exposure to COVID-19.

Thank you for helping us to maintain a healthy and safe environment. 

Do you have a fever?*
No
Yes
Do you have a cough?*
No
Yes
Do you currently have symptoms of a lower respiratory illness (e.g. cough or shortness of breath)?*
No
Yes
Please check if you are experiencing any of the following symptoms below which may be associated with COVID-19?
Runny nose/congestion
Sore Throat
Loss of sense of smell or taste
Headache Diarrhea
Rash/Skin irritation
Muscle pain/weakness
Nausea/Vomiting
Unexplained bleeding/bruising
Have you had a fever or cough in the last 7 days?*
No
Yes
Have you been in close contact with anyone who has any of the above symptoms in the last 14 days?*
No
Yes
Have you been in close contact with anyone who has been diagnosed with COVID -19 in the last 30 days?*
No
Yes
Have you travelled outside of Georgia in the last 30 days?*
No
Yes
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Your health and safety are our number one priority. In order to ensure your safety and the safety of others at WIFH, we are asking all patients to answer a few brief questions regarding possible symptoms and exposure to COVID-19.

Thank you for helping us to maintain a healthy and safe environment. 

Do you have a fever?*
No
Yes
Do you have a cough?*
No
Yes
Do you currently have symptoms of a lower respiratory illness (e.g. cough or shortness of breath)?*
No
Yes
Please check if you are experiencing any of the following symptoms below which may be associated with COVID-19?
Runny nose/congestion
Sore Throat
Loss of sense of smell or taste
Headache Diarrhea
Rash/Skin irritation
Muscle pain/weakness
Nausea/Vomiting
Unexplained bleeding/bruising
Have you had a fever or cough in the last 7 days?*
No
Yes
Have you been in close contact with anyone who has any of the above symptoms in the last 14 days?*
No
Yes
Have you been in close contact with anyone who has been diagnosed with COVID -19 in the last 30 days?*
No
Yes
Have you travelled outside of Georgia in the last 30 days?*
No
Yes
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Your health and safety are our number one priority. In order to ensure your safety and the safety of others at WIFH, we are asking all patients to answer a few brief questions regarding possible symptoms and exposure to COVID-19.

Thank you for helping us to maintain a healthy and safe environment. 

Do you have a fever?*
No
Yes
Do you have a cough?*
No
Yes
Do you currently have symptoms of a lower respiratory illness (e.g. cough or shortness of breath)?*
No
Yes
Please check if you are experiencing any of the following symptoms below which may be associated with COVID-19?
Runny nose/congestion
Sore Throat
Loss of sense of smell or taste
Headache Diarrhea
Rash/Skin irritation
Muscle pain/weakness
Nausea/Vomiting
Unexplained bleeding/bruising
Have you had a fever or cough in the last 7 days?*
No
Yes
Have you been in close contact with anyone who has any of the above symptoms in the last 14 days?*
No
Yes
Have you been in close contact with anyone who has been diagnosed with COVID -19 in the last 30 days?*
No
Yes
Have you travelled outside of Georgia in the last 30 days?*
No
Yes
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Your health and safety are our number one priority. In order to ensure your safety and the safety of others at WIFH, we are asking all patients to answer a few brief questions regarding possible symptoms and exposure to COVID-19.

Thank you for helping us to maintain a healthy and safe environment. 

Do you have a fever?*
No
Yes
Do you have a cough?*
No
Yes
Do you currently have symptoms of a lower respiratory illness (e.g. cough or shortness of breath)?*
No
Yes
Please check if you are experiencing any of the following symptoms below which may be associated with COVID-19?
Runny nose/congestion
Sore Throat
Loss of sense of smell or taste
Headache Diarrhea
Rash/Skin irritation
Muscle pain/weakness
Nausea/Vomiting
Unexplained bleeding/bruising
Have you had a fever or cough in the last 7 days?*
No
Yes
Have you been in close contact with anyone who has any of the above symptoms in the last 14 days?*
No
Yes
Have you been in close contact with anyone who has been diagnosed with COVID -19 in the last 30 days?*
No
Yes
Have you travelled outside of Georgia in the last 30 days?*
No
Yes
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Your health and safety are our number one priority. In order to ensure your safety and the safety of others at WIFH, we are asking all patients to answer a few brief questions regarding possible symptoms and exposure to COVID-19.

Thank you for helping us to maintain a healthy and safe environment. 

Do you have a fever?*
No
Yes
Do you have a cough?*
No
Yes
Do you currently have symptoms of a lower respiratory illness (e.g. cough or shortness of breath)?*
No
Yes
Please check if you are experiencing any of the following symptoms below which may be associated with COVID-19?
Runny nose/congestion
Sore Throat
Loss of sense of smell or taste
Headache Diarrhea
Rash/Skin irritation
Muscle pain/weakness
Nausea/Vomiting
Unexplained bleeding/bruising
Have you had a fever or cough in the last 7 days?*
No
Yes
Have you been in close contact with anyone who has any of the above symptoms in the last 14 days?*
No
Yes
Have you been in close contact with anyone who has been diagnosed with COVID -19 in the last 30 days?*
No
Yes
Have you travelled outside of Georgia in the last 30 days?*
No
Yes
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Your health and safety are our number one priority. In order to ensure your safety and the safety of others at WIFH, we are asking all patients to answer a few brief questions regarding possible symptoms and exposure to COVID-19.

Thank you for helping us to maintain a healthy and safe environment. 

Do you have a fever?*
No
Yes
Do you have a cough?*
No
Yes
Do you currently have symptoms of a lower respiratory illness (e.g. cough or shortness of breath)?*
No
Yes
Please check if you are experiencing any of the following symptoms below which may be associated with COVID-19?
Runny nose/congestion
Sore Throat
Loss of sense of smell or taste
Headache Diarrhea
Rash/Skin irritation
Muscle pain/weakness
Nausea/Vomiting
Unexplained bleeding/bruising
Have you had a fever or cough in the last 7 days?*
No
Yes
Have you been in close contact with anyone who has any of the above symptoms in the last 14 days?*
No
Yes
Have you been in close contact with anyone who has been diagnosed with COVID -19 in the last 30 days?*
No
Yes
Have you travelled outside of Georgia in the last 30 days?*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Your health and safety are our number one priority. In order to ensure your safety and the safety of others at WIFH, we are asking all patients to answer a few brief questions regarding possible symptoms and exposure to COVID-19.

Thank you for helping us to maintain a healthy and safe environment. 

Do you have a fever?*
No
Yes
Do you have a cough?*
No
Yes
Do you currently have symptoms of a lower respiratory illness (e.g. cough or shortness of breath)?*
No
Yes
Please check if you are experiencing any of the following symptoms below which may be associated with COVID-19?
Runny nose/congestion
Sore Throat
Loss of sense of smell or taste
Headache Diarrhea
Rash/Skin irritation
Muscle pain/weakness
Nausea/Vomiting
Unexplained bleeding/bruising
Have you had a fever or cough in the last 7 days?*
No
Yes
Have you been in close contact with anyone who has any of the above symptoms in the last 14 days?*
No
Yes
Have you been in close contact with anyone who has been diagnosed with COVID -19 in the last 30 days?*
No
Yes
Have you travelled outside of Georgia in the last 30 days?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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