COVID Examination Consent

What we are doing to prepare for your visit:

1. Our office is following CDC, Department of Health, and the American Academy recommendations.
2. Our office equipment, exam rooms, and waiting rooms are cleaned regularly.
3. We ask patients to social distance and follow our office guidelines.

Office policy regarding you visit:

1. We strongly encourage family members or visitors to wait in their cars unless the person is needed for assistance in understanding, interpretation, or safe transport of the patient to the office.
2. All patients must bring and wear masks in all areas of the facility at all times.
3. Wearing gloves is strongly discouraged.
4. Patient will only sit in the designated areas in the waiting rooms to promote social distancing.

By signing this consent and waiver for your visit you are agreeing to the following:

1. I believe my eye health is essential and that my office visit is essential to maintain eye health.
2. I understand that there is no way to eliminate all potential exposure to COVID -19 when I visit and travel to and from my Doctors facility, but I am willing to assume the risks.
3. I understand that COVID -19 infection can lead to illness, disability, or even death and knowingly assume the risk of exposure as I deem my eye exam to be essential to the maintenance of my vision.
4. I will not hold Mid Atlantic Retina, its doctors or staff legally responsible should I become positive or presumptively diagnosed with the COVID-19 virus.