Healthcare COVID Policy

HEALTHCARE COVID POLICY

Facility Name:

Patient Information

Date of Birth:    Gender:

Insurance Information

Medical & COVID-Specific Health Information

Vaccination status (check all that apply):
Fully vaccinated   Partially vaccinated   Not vaccinated   Decline to state

Within the past 14 days, I have experienced: (check all that apply)
Fever or chills   New or worsening cough   Shortness of breath or difficulty breathing   Loss of taste or smell

I have had known close contact with a confirmed COVID-19 case within the past 14 days:
Yes   No

Screening, Testing & Isolation

I understand that the facility may perform screening measures including symptom questionnaires, temperature checks, and point-of-care testing when indicated. I consent to COVID-19 testing if clinically recommended by facility staff for the purpose of diagnosis and infection control.

I acknowledge that if I test positive for COVID-19 or report symptoms consistent with COVID-19, I may be required to leave the facility, be isolated, defer elective or non-urgent care, or have appointments converted to telehealth to protect other patients and staff. I agree to comply with all isolation and return-to-care requirements established by the facility.

I authorize the facility to disclose my COVID-19 test results and related clinical information to public health authorities and other health care providers as required by law for disease reporting and contact tracing.

Masking, PPE & Visitor Policy

I agree to follow the facility's masking and personal protective equipment (PPE) requirements while inside the facility, including wearing a mask that covers nose and mouth when required. I understand that failure to comply may result in denied entry or deferred services.

Visitor access may be limited based on infection control policies. I acknowledge that accompanying persons may be screened and that the facility may restrict visitors for safety reasons.

Privacy, Data Use & Confidentiality

The facility will maintain confidentiality of health information consistent with applicable privacy laws. I understand that information collected as part of COVID-19 screening and testing may be recorded in my medical record and shared with authorized health care personnel and public health authorities in accordance with law.

By signing below I acknowledge that I have read, or had explained to me, the facility's COVID-19 policy, including screening procedures, testing and isolation protocols, masking requirements, and information sharing for public health purposes. I understand my responsibilities and agree to comply with the policy while receiving care.

Acknowledgments & Consents

I acknowledge receipt of the Healthcare COVID Policy and understand the content herein.

I give consent for COVID-19 testing if recommended during my care at this facility.

I authorize necessary disclosure of my COVID-related health information to public health agencies and other health care providers as required.

Patient Certification

I certify under penalty of perjury that the information I have provided on this form is true and correct to the best of my knowledge. I understand that intentional misrepresentation of symptoms, exposure, or vaccination status may affect my treatment and could have legal consequences.

I understand that this Policy may be revised to reflect changes in public health guidance and that the facility will notify patients as required. My signature below confirms my understanding and agreement to comply with the facility COVID policies in effect at the time of my visit.

Sign Now