Covid Form

This document contains important information about conducting 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.

You understand that by coming to the office, you are assuming the risk of exposure to the COVID-19 (or other public health risk).

To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, and our families, and other patients) safer from exposure, sickness and possible death. You will only keep your in-person appointment if you are symptom free. You will take your temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the COVID-19, you agree to cancel the appointment or proceed using telehealth. If you wish to cancel for this reason, you will not be charged our normal cancellation fee. You will wait in your car or outside [or in a designated safer waiting area] and notify me when you arrive. You will remain outside until you are notified to come up to the office. You will wash your hands or use alcohol-based hand sanitizer when you enter the building. You will adhere to the safe distancing precautions we have set up in the waiting room and testing/therapy room. For example, you won’t move chairs or sit where we have signs asking you not to sit. You will wear a mask in all areas of the office (I will too) You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands). You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands. If you are bringing your child, you will make sure that your child follows all of these sanitation and distancing protocols as best as possible. You will take steps between appointments to minimize your exposure to COVID-19. If you have a job that exposes you to other people who are infected, you will immediately let me know. If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let me know. If a resident of your home tests positive for the infection, you will immediately let me know and we will postpone in-person appointments or use telehealth when possible. I may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.

My practice has taken steps to reduce the risk of spreading the COVID-19 within the office. Please let me know if you have questions about these efforts.

You understand that I am committed to keeping you, me, 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 require you to leave the office immediately. 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/business agreement that we agreed to at the start of our work together. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child and I may be exposed to or infected by COVID-19 by engaging in services with Dr. Heidi Cherwony and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the office of Dr. Heidi Cherwony may result from the actions, omissions, or negligence of me and others, including, but not limited to building staff, other professionals in the building and their clients. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any illness my child or I may incur in connection with services provided. On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless Dr. Heidi Cherwony any claims, including all liabilities, actions, damages, costs or expenses of any kind arising out of or relating to COVID-19. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of Dr. Heidi Cherwony, whether a COVID-19 infection occurs before, during, or after services provided.