Healthcare Infectious Diseases Agreement

HEALTHCARE INFECTIOUS DISEASES AGREEMENT

Patient Name:    Date of Birth:    Gender:

Patient Information

Insurance Information

Medical History

Symptoms and Exposure

Are you currently experiencing any of the following symptoms? (Check all that apply)

Fever or chills    New or worsening cough    Shortness of breath    Sore throat

Known recent exposure to a confirmed infectious disease case: Yes    If yes, date of exposure:

Vaccination Status

Please indicate vaccination history (check all that apply):

Completed COVID-19 primary series    COVID-19 booster received    Recent influenza vaccine    Other vaccines (specify below)

Consent, Authorization and Acknowledgments

I understand that the healthcare facility has protocols to reduce the transmission of infectious diseases, which may include screening, testing, isolation, use of personal protective equipment (PPE), visitor restrictions, and deferred/non-urgent procedures where clinically appropriate. I acknowledge that these measures are for the protection of patients, staff, and the public.

By initialing and checking the boxes below I provide the following authorizations and acknowledgments:

I consent to testing for infectious agents as clinically indicated (e.g., respiratory viral testing, bacterial cultures, blood tests).
I consent to medically necessary treatment related to an infectious disease diagnosis, including administration of antimicrobial agents, oxygen, and supportive care.
I authorize collection and laboratory testing of specimens (e.g., swabs, blood) and retention/disposal of specimens according to standard laboratory policy.
I agree to comply with isolation, quarantine, and other infection-control measures imposed by the facility or public health authorities while under care.
I authorize the facility to disclose my protected health information to public health authorities, contact tracers, and other entities as required by law for reporting and control of infectious diseases.

I understand that refusal of recommended testing or isolation may affect the ability of the facility to provide certain services or permit visitation, and may require referral to alternate care settings. I acknowledge that the facility cannot guarantee complete protection from exposure to infectious agents within the healthcare environment.

(If left blank, authorization will expire one year from the date of signature unless otherwise required by law.)

HIPAA / Privacy Acknowledgment

The facility will protect your health information in accordance with applicable privacy laws. By signing this agreement you acknowledge receipt of the facility's privacy practices summary and permit necessary disclosures to public health authorities, other treating providers, and persons involved in your care as permitted by law.

I acknowledge that I have been provided the facility's privacy practices summary and understand how my information may be used and disclosed in the context of infectious disease control.

Attestation

I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I understand that this document authorizes actions necessary for diagnosis, treatment, and public health reporting of infectious diseases and that I may withdraw this authorization in writing, subject to legal constraints and the facility's obligations for reporting and public safety.

I attest that the information above is accurate and I understand the consents and acknowledgments contained in this agreement.

Sign Now