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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: August 19, 2022

First Patients Name

First Name*

Last Name*
First Patients Date of Birth*
I certify that I am 18 years of age or older
First Patients 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. 

Have you had a fever in the past 24 hours? *
No
Yes
In the past 2 weeks, have you experienced any flu-like symptoms including persistent cough, runny nose, chills, body aches, fatigue, sore throat, headache or diarrhea? *
No
Yes
In the past two weeks, have you lost your sense of taste or smell? *
No
Yes
In the past 2 weeks, have been exposed to anyone who has been diagnosed with Covid 19? *
No
Yes
In the past two weeks, have you been diagnosed with COVID 19? *
No
Yes
Have you been vaccinated against COVID 19?
No
Yes
First Patients Signature*
Second Patients Name

First Name*

Last Name*
Second Patients Date of Birth*
Second Patients 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. 

Have you had a fever in the past 24 hours? *
No
Yes
In the past 2 weeks, have you experienced any flu-like symptoms including persistent cough, runny nose, chills, body aches, fatigue, sore throat, headache or diarrhea? *
No
Yes
In the past two weeks, have you lost your sense of taste or smell? *
No
Yes
In the past 2 weeks, have been exposed to anyone who has been diagnosed with Covid 19? *
No
Yes
In the past two weeks, have you been diagnosed with COVID 19? *
No
Yes
Have you been vaccinated against COVID 19?
No
Yes
Third Patients Name

First Name*

Last Name*
Third Patients Date of Birth*
Third Patients 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. 

Have you had a fever in the past 24 hours? *
No
Yes
In the past 2 weeks, have you experienced any flu-like symptoms including persistent cough, runny nose, chills, body aches, fatigue, sore throat, headache or diarrhea? *
No
Yes
In the past two weeks, have you lost your sense of taste or smell? *
No
Yes
In the past 2 weeks, have been exposed to anyone who has been diagnosed with Covid 19? *
No
Yes
In the past two weeks, have you been diagnosed with COVID 19? *
No
Yes
Have you been vaccinated against COVID 19?
No
Yes
Fourth Patients Name

First Name*

Last Name*
Fourth Patients Date of Birth*
Fourth Patients 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. 

Have you had a fever in the past 24 hours? *
No
Yes
In the past 2 weeks, have you experienced any flu-like symptoms including persistent cough, runny nose, chills, body aches, fatigue, sore throat, headache or diarrhea? *
No
Yes
In the past two weeks, have you lost your sense of taste or smell? *
No
Yes
In the past 2 weeks, have been exposed to anyone who has been diagnosed with Covid 19? *
No
Yes
In the past two weeks, have you been diagnosed with COVID 19? *
No
Yes
Have you been vaccinated against COVID 19?
No
Yes
Fifth Patients Name

First Name*

Last Name*
Fifth Patients Date of Birth*
Fifth Patients 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. 

Have you had a fever in the past 24 hours? *
No
Yes
In the past 2 weeks, have you experienced any flu-like symptoms including persistent cough, runny nose, chills, body aches, fatigue, sore throat, headache or diarrhea? *
No
Yes
In the past two weeks, have you lost your sense of taste or smell? *
No
Yes
In the past 2 weeks, have been exposed to anyone who has been diagnosed with Covid 19? *
No
Yes
In the past two weeks, have you been diagnosed with COVID 19? *
No
Yes
Have you been vaccinated against COVID 19?
No
Yes
Sixth Patients Name

First Name*

Last Name*
Sixth Patients Date of Birth*
Sixth Patients 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. 

Have you had a fever in the past 24 hours? *
No
Yes
In the past 2 weeks, have you experienced any flu-like symptoms including persistent cough, runny nose, chills, body aches, fatigue, sore throat, headache or diarrhea? *
No
Yes
In the past two weeks, have you lost your sense of taste or smell? *
No
Yes
In the past 2 weeks, have been exposed to anyone who has been diagnosed with Covid 19? *
No
Yes
In the past two weeks, have you been diagnosed with COVID 19? *
No
Yes
Have you been vaccinated against COVID 19?
No
Yes
Seventh Patients Name

First Name*

Last Name*
Seventh Patients Date of Birth*
Seventh Patients 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. 

Have you had a fever in the past 24 hours? *
No
Yes
In the past 2 weeks, have you experienced any flu-like symptoms including persistent cough, runny nose, chills, body aches, fatigue, sore throat, headache or diarrhea? *
No
Yes
In the past two weeks, have you lost your sense of taste or smell? *
No
Yes
In the past 2 weeks, have been exposed to anyone who has been diagnosed with Covid 19? *
No
Yes
In the past two weeks, have you been diagnosed with COVID 19? *
No
Yes
Have you been vaccinated against COVID 19?
No
Yes
Eighth Patients Name

First Name*

Last Name*
Eighth Patients Date of Birth*
Eighth Patients 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. 

Have you had a fever in the past 24 hours? *
No
Yes
In the past 2 weeks, have you experienced any flu-like symptoms including persistent cough, runny nose, chills, body aches, fatigue, sore throat, headache or diarrhea? *
No
Yes
In the past two weeks, have you lost your sense of taste or smell? *
No
Yes
In the past 2 weeks, have been exposed to anyone who has been diagnosed with Covid 19? *
No
Yes
In the past two weeks, have you been diagnosed with COVID 19? *
No
Yes
Have you been vaccinated against COVID 19?
No
Yes
Ninth Patients Name

First Name*

Last Name*
Ninth Patients Date of Birth*
Ninth Patients 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. 

Have you had a fever in the past 24 hours? *
No
Yes
In the past 2 weeks, have you experienced any flu-like symptoms including persistent cough, runny nose, chills, body aches, fatigue, sore throat, headache or diarrhea? *
No
Yes
In the past two weeks, have you lost your sense of taste or smell? *
No
Yes
In the past 2 weeks, have been exposed to anyone who has been diagnosed with Covid 19? *
No
Yes
In the past two weeks, have you been diagnosed with COVID 19? *
No
Yes
Have you been vaccinated against COVID 19?
No
Yes
Tenth Patients Name

First Name*

Last Name*
Tenth Patients Date of Birth*
Tenth Patients 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. 

Have you had a fever in the past 24 hours? *
No
Yes
In the past 2 weeks, have you experienced any flu-like symptoms including persistent cough, runny nose, chills, body aches, fatigue, sore throat, headache or diarrhea? *
No
Yes
In the past two weeks, have you lost your sense of taste or smell? *
No
Yes
In the past 2 weeks, have been exposed to anyone who has been diagnosed with Covid 19? *
No
Yes
In the past two weeks, have you been diagnosed with COVID 19? *
No
Yes
Have you been vaccinated against COVID 19?
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
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.

By signing below the parent or court-appointed legal guardian agrees that they are also 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. 

Have you had a fever in the past 24 hours? *
No
Yes
In the past 2 weeks, have you experienced any flu-like symptoms including persistent cough, runny nose, chills, body aches, fatigue, sore throat, headache or diarrhea? *
No
Yes
In the past two weeks, have you lost your sense of taste or smell? *
No
Yes
In the past 2 weeks, have been exposed to anyone who has been diagnosed with Covid 19? *
No
Yes
In the past two weeks, have you been diagnosed with COVID 19? *
No
Yes
Have you been vaccinated against COVID 19?
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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