COVID-19

Notification and Acknowledgment Form

(NAME OF PRACTICE) prioritizes the health and well-being of our patients and staff above all
else. To meet this objective, we are working hard and in coordination with the Federal, State
and local recommendations to ensure that we are implementing all appropriate changes to our
operations, protocols and procedures as quickly as possible.

Despite the increased precautions that we are taking to reduce the risk of infection, it is
important to recognize the risk of exposure to the coronavirus when you are in our office or
procedure center.

To be clear, high-risk patients are at a higher risk of death in the event that they become
infected with COVID-19.

High-Risk COVID-19 patients may fall into these categories:

- Individuals 70 years old or older;
- Individuals with severe lung disease (COPD, asthma, pulmonary hypertension, pulmonary
fibrosis, cystic fibrosis, oxygen dependent, etc.);
- Individuals with severe heart disease (heart attack/stent/bypass surgery in the past six
months, history of congestive heart failure, etc.);
- Individuals who are immunosuppressed with CD4 count <200 or those taking
immunocompromising medications (e.g. prednisone >20mg/day, chemotherapy,
mycophenalate, cyclosporine, azathioprine, tacrolimus, TNF inhibitors, monoclonal antibodies,
etc.)

Also, please note, that even if you are not a high risk COVID-19 patient, you are still at risk of
harm from COVID-19. It was recently reported that 40% of the patients hospitalized for
COVID-19 were younger than 55 years old.

Recommendations:
1. The majority of office visits are being switched to telehealth or virtual visits to reduce the risk
of exposure to patients and staff.
2. “High-Risk COVID-19” patients should isolate themselves and strongly consider whether or
not they should be at our clinic or procedure center.
3. Only essential pain procedures are to be completed.
4. At this time, essential procedures are defined as severe, unbearable pain that would make it
impossible to postpone the procedure without likely serious negative repercussions or a
procedure that is required to prevent or reduce the likelihood of permanent damage or harm.
5.Essential procedures will be considered on a case-by-case basis, taking into consideration
the patient’s pain status and the health and age of the patient, especially given the risks of
concurrent COVID-19 infection.

I acknowledge that I have read and understand the information above and have had questions
answered.

Patient Signature: _______________________________

Patient Name: __________________________________

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