Clarks Summit PA
Downtown Scranton PA
North Scranton PA
West Pittston PA
COVID In-Office Informed Consent
COVID In Office Informed Consent
I agree to meet in person
Decision to Meet Face-to-Face
We have agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, either of us may desire to again meet via telehealth. If you have concerns about meeting through telehealth, we will talk about it first and try to address any issues. You understand that, if I believe it is necessary, I may determine that we return to telehealth for everyone’s well-being.
If you decide at any time that you would feel safer staying with, or returning to, telehealth services, I will respect that decision, as long as it is feasible and clinically appropriate. Reimbursement for telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue we may also need to discuss.
You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service.
I understand my responsibilities
You will only keep your in-person appointment if you are symptom free.
You will take your temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth. ___
You will wash your hands or use alcohol-based hand sanitizer when you enter the building.
You will adhere to the safe distancing precautions and not won’t move chairs or sit in such a way that would not conform to social distancing guidelines.
You will be compliant with the Commonwealths guidance regarding masking while in public settings.
We will agree to both respect a distance of 6 feet at all times whenever possible and feasible.
You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands.
If you are bringing your child, you will make sure that your child follows all of these sanitation and distancing protocols.
You will take steps between appointments to minimize your exposure to COVID.
If a resident of your home tests positive for the infection, you will immediately let me know and we will then begin / resume treatment via telehealth.
I understand the Therapist's responsibility
We have taken steps to reduce the risk of spreading the coronavirus within the office will continue to make all reasonable efforts to minimize everyone exposure. Please let me know if you have questions about these efforts.
What happens if either of us are sick
You understand that I am committed to keeping you, me, and all of our families safe from the spread of this virus. If you show up for an appointment and I believe that you have a fever or other symptoms, or believe you have been exposed, I may ask to leave the office immediately and follow up with services by telehealth as appropriate.
If I test positive for the coronavirus, I will notify you so that you can take appropriate precautions.
If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release.
This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together.
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William (Bill) Rusen
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