COVID-19 Pandemic Essential Eye Exam and Treatment Consent Form Patient Name First Last DOB Date Format: MM slash DD slash YYYY Appointment Date Date Format: MM slash DD slash YYYY Please read the following statements and initial next to the following statements to indicate your agreement. If you cannot positively affirm to all of these questions, you will be asked to postpone or reschedule your visit to a later dateUntitled* I do not currently, nor have I had in the last two weeks, a fever, cough, sore throat, loss of smell/taste or other cold symptoms To the best of my knowledge, I do not have, nor have I been in direct contact with someone who has confirmed diagnosis of COVID-19 or a presumptive positive COVID-19 test result in the last 30 (thirty) days. Neither I, nor anyone living in my immediate household, have traveled outside of the state in the last 30 (thirty) days. Read Before Signing: I have read the health questions above and have answered them honestly and to the best of my knowledge. I understand that North Garland Vision, its doctors and staff are taking precautions to limit any potential exposure I may have to the COVID-19 virus. I also understand that there is no definitive way to eliminate potential exposure by one hundred percent. By signing this form below, I agree that I will not hold North Garland Vision or any of its doctors or staff personally responsible should I, or someone I come in contact with, become positive or presumptively positive diagnosed with the COVID-19 virus. There are certain inherent risks associated with an eye exam during a pandemic and I assume full responsibility for personal illness that may result and further release and discharge North Garland Vision and its doctors and staff for injury, loss or damage arising out of my visit. I understand that COVID-19 infection can lead to illness, disability, or even death and knowingly take the risk of exposure as I deem my eye exam to be essential to the maintenance of my vision. I, the undersigned, affirm that I am at least 18 years of age and am freely signing this agreement or that I am signing on behalf of a minor child that I have the legal authority to sign such agreements on behalf of. I have read this form and fully understand it. Name of Patient First Last Date Date Format: MM slash DD slash YYYY SignatureName of Signer if Different from PatientRelationship to Patient
