Please Fill Out The Pre Screening Consent Form

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.
· COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be
contagious.
· I am the decision maker for my health care. Part of this care providers 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. Please tick for approval

I KNOWINGLY & WILLINGLY CONSENT TO THIS TREATMENT WITH THE FULL UNDERSTANDING AND
DISCLOSURES OF ANY 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. 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 HERE, FOR MY PRESENT
CONDITION AND FOR ANY FUTURE CONDITIONS.