Screening/Disclosure Form for Patients During Covid-19 Epidemic

The above information given by me is true to the best of my knowledge, I fully understand and acknowledge that withholding or mis-representation of any information is highly unethical and against the interest of larger
population during this pandemic.

I understand the Covid-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I fully understand and acknowledge that I / my patient may be an
asymptomatic carrier of the disease / undiagnosed patient with COVID19. I confirm that it is my / my patient’s responsibility to take appropriate precautions and strictly comply with all safety precautions and protocols advised
as not doing so may endanger doctors and clinic staff.

I also understand that, due to the contagious nature of the disease, the fact that I could have been in the incubation period and not be aware, and/or characteristics of procedures and being at a clinic despite best disinfection
protocols applied, I / my patient could develop an infection later.

In the eventuality of my testing covid positive at a later date, I will not hold the clinic/staff / management responsible for it. I hereby knowingly and willingly give consent to have my investigations and
treatment completed during the Covid pandemic.