Healthcare COVID Protocols

HEALTHCARE COVID PROTOCOLS

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group #:

Medical History (relevant to COVID-19)

COVID-19 Screening (to be completed at each visit)

Within the past 14 days, have you experienced any of the following? (Check all that apply)

Fever or chills
New or worsening cough
Shortness of breath or difficulty breathing
Unusual fatigue or muscle aches
New loss of taste or smell
Sore throat
Nausea, vomiting, or diarrhea

Within the past 14 days, have you had known close contact with someone with confirmed or suspected COVID-19?   Yes No

Have you traveled to an area with high community transmission or had substantial public exposure in the last 14 days?   Yes No

Vaccination and Testing

Vaccination status (select all that apply):

Fully vaccinated
Partially vaccinated
Not vaccinated

If vaccinated, enter vaccine details:

Vaccine Type:    Date of Most Recent Dose:

Have you received a COVID-19 booster?   Yes No

Facility COVID Controls & Patient Responsibilities

I acknowledge that the healthcare facility maintains infection prevention controls which may include symptom screening, facility masking requirements, physical distancing, hand hygiene, and environmental cleaning. I agree to comply with facility instructions regarding masks, entry screening, directed testing, and temporary isolation if indicated. Noncompliance may result in deferral of services until compliance is achieved or an appropriate care plan is determined.

I understand that there is an inherent risk of exposure to infectious disease when entering any clinical environment. The facility will take reasonable measures to mitigate risk but cannot guarantee zero risk of transmission. By signing below I accept these risks as part of receiving care.

Consent for Testing and Information Use

By initialing and signing, I authorize the facility to perform diagnostic testing for SARS-CoV-2 (COVID-19) as clinically indicated. I consent to collection of relevant specimens, use of test results in my clinical record, and disclosure of results as required for treatment, care coordination, and public health reporting. Tests may include molecular, antigen, or other validated assays.

Consent to testing: I consent I do not consent

Privacy, Data Retention, and Reporting

I acknowledge that medical information, including COVID-19 test results, may be retained in my medical record and shared with public health authorities or other entities as required by law for contact tracing, surveillance, or outbreak control. The facility will store and process such information in accordance with applicable privacy laws and internal retention policies.

I consent to limited use of my contact information to notify me of test results, required isolation guidance, or changes to my scheduled appointments related to infection control.

Acknowledgment and Agreement

By signing below I certify the accuracy of the information provided on this form to the best of my knowledge. I understand the facility's COVID-19 protocols and agree to comply. I acknowledge that circumstances and protocols may change and that the facility may update procedures to align with clinical guidance. I may withdraw consent for testing at any time, subject to clinical and public health obligations.

Additional Notes (staff use or patient comments)

Sign Now