For appointments: 1 203 661 7546|40 West Elm Street, Greenwich CT 06830
For appointments call 1 203 661 7546

 

 

COVID-19 RISK INFORMED CONSENT

Greenwich Dermatology
Dr. Henry Gasiorowski
Dr. Michele Gasiorowski
40 West Elm Street
Greenwich, CT 06830

Our office complies with the State Health Department and CDC guidelines to prevent the COVID-19 virus.  In order to reduce the risk of spreading COVID 19 and for the safety of our staff, other patients, and yourself, please read the below consent and complete the screening questions no more than 24 hours prior to your scheduled visit/treatment/procedure/surgery.

I understand that I am opting to visit Greenwich Dermatology for an elective visit/treatment/procedure/surgery that may not be urgent and may not be medically necessary.

I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact and, as a result, federal and state health agencies recommend social distancing. I recognize that Dr. Henry Gasiorowski, Dr. Michele Gasiorowski and all the staff at Greenwich Dermatology are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of visiting their office. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this interaction and I give my express permission for Greenwich Dermatology to proceed with the same.

I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that, if I have a COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this visit/treatment can lead to a higher chance of complication and death.

I understand that COVID-19 may cause additional risks, some or may of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the visit/treatment/procedure/surgery itself. I have been given the option to defer my treatment/procedure/surgery to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired visit/treatment/procedure/surgery.