Informed Consent for In-Person Services During COVID-19 Informed Consent for In-Person Services The Pisgah Institute (TPI) INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS OR OTHER HEALTH CRISISThis document contains important information about our decision (yours and mine) to resume in-person services in light of the COVID-19 public health crisis. 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-FaceWe 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, I may require that we meet via telehealth. Or suspend services. 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. Risks of Opting for In-Person ServicesYou understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). 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. Your Responsibility to Minimize Your ExposureTo obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, our families, our staff, and other patients) safer from exposure and sickness. If you do not adhere to these safeguards, it may result in our starting/returning to a telehealth arrangement. 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. ConsentThe following requirements might change if additional local, state, or federal orders or guidelines are published. If that happens, necessary changes will be discussed. Please consent to the following items to indicate that you understand and agree to these actions. I will only keep my in-person appointment if I am symptom free.* I agree. I do not agree. If I have other of COVID-19 (cough, runny nose, shortness of breath, chills, fever, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell, diarrhea, etc.), I agree to cancel the appointment or proceed using telehealth, if possible. If I wish to cancel for this reason, I will not be charged the usual cancellation fee.* I agree. I do not agree. I will wait to come into the office until I am notified that my provider is ready to meet with me.* I agree. I do not agree. I will wash my hands or use alcohol-based hand sanitizer when I enter the building.* I agree. I do not agree. I will adhere to the safe distancing precautions we have set up in the waiting room and testing/TMS room. For example, I will not move chairs or sit where there are signs asking me not to sit.* I agree. I do not agree. I will wear a mask in all areas of the office. TPI staff will also wear a mask except when testing, in which case there will be a plexiglass screen between the clinician and patient.* I agree. I do not agree. I will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands).* I agree. I do not agree. I will take steps between appointments to minimize my exposure to COVID-19.* I agree. I do not agree. If I have a job that exposes me to other people who are infected, I will immediately let TPI staff know.* I agree. I do not agree. If a resident of my home or regular contact tests positive for the infection, I will immediately notify TPI staff and we will then begin (or resume) treatment via Telehealth, if possible.* I agree. I do not agree. TPI Commitment to Minimize ExposureTPI has taken steps to reduce the risk of spreading the COVID-19 within the office, and we have posted these steps on our website and in the office. Please let us know if you have questions about them.If You or I/Someone in My Office is SickYou understand that I am committed to keeping you, me, our staff, and all of our families safe from the spread of this virus. If you show up for an appointment and I believe that you have a fever or other symptoms, or believe you have been exposed, I will have to leave the office immediately. We can follow up with services by telehealth as appropriate. If I test positive for the COVID-19, I will notify you so that you can take appropriate precautions. Your Confidentiality in the Case of InfectionIf you have tested positive for the COVID-19, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release.Informed ConsentThis agreement supplements the general informed consent agreement that we agreed to at the start of our work together. Your signature below shows that you agree to these terms and conditions.Your Printed Name* Name of Minor or Dependent Adult Patient if other than self Patient Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature* **For the purpose of completing this form digitally, I attest that my typed signature can be used in place of a physical signatureCAPTCHANameThis field is for validation purposes and should be left unchanged.