Center Line Veterinary Hospital

26242 Van Dyke Avenue
Center Line, MI 48015

(586)758-5620

www.centerlinevet.com

 

Client COVID-19 Informed Consent Form

 

Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as "Coronavirus", at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.

Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. "Social Distancing" nationwide has reduced the transmission of the Coronavirus.

Because we have taken measures to provide social distancing in our practice, we will only allow one adult inside our exam room with the pet(s). We will also have one of our staff members hold your pet when the doctor performs their comprehensive examination on your pet(s). As an owner, you will be asked to stay seated while this is taking place.

 

COVID-19 Questionnaire Form

Although exposure is unlikely, do you accept the risk and consent to be in our facility and agree to the above terms? (required)
Yes
No
Client Name: (required)

Client Phone Number: (required)

Pet Name: (required)

Parking Spot: (required)

Within the past 14 days, have you been in close contact with anyone that you know who has had COVID-19 or COVID-like symptoms? (required)
Yes
No
Have you had a positive COVID-19 test for the active virus in the past 10 days, or are you awaiting results of a COVID-19 test? (required)
Yes
No
Have you had close contact (within 6 feet for 15 minutes or more over a 24-hour period with a person; or have had direct contact with fluids from a person with COVID-19 with or without wearing a mask (i.e. coughed or sneezed on) within the past 10 days? (required)
Yes
No
Within the past 14 days, has a public health or medical professional told you to self-monitor, self isolate, or self-quarantine because of concerns about COVID-19 infection? (required)
Yes
No
Several of our staff are fully vaccinated, however, there are some that have chosen not to vaccinate. Because of this, until July 1st (assuming the governor will be releasing all mask mandates) you will see some of our staff “unmasked” and “masked”.
If for any reason, you would like us to mask in your presence, please let one of our receptionists know. Also, if you are fully vaccinated (two weeks past your vaccine) and chose to not wear a mask, we ask to see your vaccine card.
Again, until all restrictions are lifted, we need to keep all our employees safe. We thank you for understanding.

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