Consent and AcknowledgementChieftain2020-09-01T12:36:48-05:00
I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that St. John’s UMC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19, and I affirm that I will follow the procedures laid out for me in order to protect the health and safety of myself and others.
I acknowledge that I am increasing my risk of exposure to the Coronavirus/COVID-19.
I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
I attest that:
I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
I have not traveled internationally within the last 14 days.
I have not traveled to a highly impacted area within the United States of America in the last 14 days.
I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as noncontagious by state or local public health authorities.
I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.