Informed Consent for In-Person Services During COVID-19

This 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.

We 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.

You 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.

To 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.

The 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.

TPI 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.

You 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.

If 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.

This 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.