Healthcare Covid Policies Form

HEALTHCARE COVID POLICIES FORM

Patient Information

Patient Name:    Date of Birth:

Insurance Information

Medical History (Relevant to Infection Control)

COVID-19 Screening and Status

In the past 14 days have you experienced fever, cough, shortness of breath, loss of taste or smell, sore throat, or other flu-like symptoms?

Yes    No

Have you tested positive for COVID-19 within the last 30 days?

Yes    No

COVID-19 vaccination status:
Fully vaccinated    Partially vaccinated    Not vaccinated    Booster received

Facility COVID-19 Policies (Important Notices)

Infection control measures: The facility maintains screening, masking, enhanced cleaning, physical distancing, and staff testing protocols to reduce transmission risk. Patients and visitors are required to comply with posted instructions. The facility may refuse or limit services for non-compliance where necessary to protect patients, staff, and the public.

Screening and testing: By entering the facility you consent to symptom screening, temperature checks, and testing if clinically indicated. You authorize the facility to collect and record screening results and to take appropriate isolation measures when required by infection control protocols.

Visitor policy: Visitor access may be restricted based on current transmission levels, vaccination status, patient clinical condition, and public health recommendations. Exceptions for end-of-life or support needs may be granted at clinical discretion.

Patient Obligations, Notification, and Consent

I acknowledge that I have read and understand the facility's COVID-19 policies summarized above. I understand that despite mitigation efforts there remains a risk of exposure to COVID-19 and other communicable diseases during my visit. I voluntarily assume that risk.

I consent to: symptom and temperature screening; COVID-19 testing if clinically indicated; and temporary isolation or modification of services to reduce transmission risk. I agree to follow staff instructions and infection control measures while on premises.

I agree to notify the facility within 72 hours if I test positive for COVID-19 following an in-person visit to enable timely exposure assessment and notifications as required by public health protocols.

HIPAA / Privacy Acknowledgment

I acknowledge that the facility may disclose limited COVID-19 related health information to public health authorities, contact tracing entities, or other entities as required by law. I acknowledge receipt of the facility's privacy practices regarding protected health information and COVID-19 related disclosures.

I understand I may withdraw consent to certain non‑mandated policies in writing, but withdrawal will not affect actions taken prior to receipt of such withdrawal. I understand that refusal to comply with mandatory infection control measures may result in postponement or denial of services when necessary for safety.

Authorization Period

This acknowledgment and authorization remains in effect until: or until revoked in writing as described above.

Attestations

By signing below I certify under penalty of law that the information I have provided on this form is true and correct to the best of my knowledge. I understand that providing false information may affect my access to care and may be subject to legal penalties where applicable.

I acknowledge I have had the opportunity to ask questions about these policies and have received answers. I agree to comply with the facility's COVID-19 policies during visits and understand instructions given by clinical staff regarding infection control.

Sign Now