Patient Authorization/Consent to Treat during COVID-19

In Office Visit During COVID

Patient Authorization and Consent

During the COVID-19 pandemic, there is increased risk for patients who visit a healthcare provider. Health problems can happen from being exposed to:
- other patients
- healthcare staff, or
- healthcare facilities
Some patients have a higher risk of complications from COVID-19, including those with:
- asthma
- chronic lung disease
- serious heart disease or problems
- chronic kidney disease
- obesity
- a compromised or suppressed immune system
- liver disease
- pregnant
- age 65 or older, or
- nursing home, long-term care facility, or retirement community residents
If high-risk patients get COVID-19, they may have a greater chance for having more health problems, some of which may be serious or life threatening, and may require hospitalization.

There may be other ways to communicate or meet with your health care provider and be evaluated and treated. You could have:
- Telehealth evaluation and/or treatment
- Medicare e-visit
Telehealth may or may not be right for you. This depends on your health problem and overall health. If remote assessment and treatment are not appropriate, your health care provider will explain why you need an in-person visit.

Office staff may help your health care provider when you arrive and while you are evaluated and treated. They will follow state laws and recommendations from local, state, and national regulatory and public health officials related to caring for patients during the COVID-19 pandemic. However, they cannot eliminate all risks, especially for high-risk patients.

The first page of this consent form told you about COVID-related risks. If, after reviewing this form, you do not believe that you really understand the risks and choices, please initial this line and do not sign the form below until all of your questions have been answered.

I understand the facts provided to me on the first page of this consent form. I give my consent for in-office evaluation and treatment. By signing below, I agree that Prana has discussed the facts in this form with me, that no one has given me any guarantee, that I have had a chance to ask questions, and that all of my questions have been answered.
Name of Patient
First Last
Signature of Patient or Responsible Party*
Date*
MM slash DD slash YYYY
Time

: Hours

Minutes

AM/PM
Relationship to Patient (if Responsible Party is not Patient)
Witness
First Last
Date
MM slash DD slash YYYY

I have never experienced anything like Prana Physical Therapy. The staff is courteous and you instantly feel like you've known them for a long time. It starts at the front desk with Stephanie or Natalie, both are very pleasant and efficient at their job. I rotate visits between three therapists and there is never any breakdown in communication. My therapy remains consistent and effective. The surroundings are beautiful, clean and bursting with positive energy!

In Office Visit During COVID

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