COVID-19 Pandemic Treatment Consent Form

Name: Hopkins Eye Center, PA
Address: 3900 South Highway 14, Suite D, Greenville, SC, 29615, US
Telephone: 864-234-5335
Price range: $000 - $300

Patient's Name*
First Last
Date*
MM slash DD slash YYYY
Caregiver Name and Relation to Patient*
Consent
I knowingly and willingly consent to have optometric treatment and care at Hopkins Eye Center PA during and after the COVID-19 pandemic.
Consent
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and will still be highly contagious. It is impossible to determine who has it and who does not, given the current limits in virus testing.
Consent
I understand that any type of travel significantly increases the risk of contracting and transmitting COVID-19 virus. I verify that I or s/he have not traveled by plane, train, or bus outside of South Carolina in the past 14 days.
Signature