Whole Child Pediatrics

Available Forms

Covid Consent Form

Patient Name

Patient Date of Birth

I knowingly and willingly consent to have treatment completed during the COVID-19 pandemic at Ideal Pediatrics. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.

I understand due to the frequency of visits of other patients, the characteristics of the virus, and the characteristics of potential procedures, that I have an elevated risk of contracting the virus simply by being in a medical office.

I confirm that I am NOT presenting with any of the listed symptoms of COVID-19.

Fever Shortness of Breath Dry Cough Runny Nose Sore Throat Sneezing, Watery Eyes, or Sinus Pain Headaches, Fatigue or weakness Loss of sense of taste or smell

I understand the the CDC recommends social distancing of at least 6 feet and that this will NOT be possible with your treatment.

I verify that I have not traveled outside the United States in the past 14 days to countries that have been affected by COVID-19.

I verify that I have not traveled domestically within the United States by commercial airline, bus or train within the past 14 days.

Authorized Adult

Indicates signature and acknowledgment

Today's date

* Required field