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ABC Pediatric Therapy, LLC
SUPPLEMENTAL INFORMED CONSENT FOR TREATMENT
  • I hereby acknowledge receipt of the COVID-19 Safety Guidelines for ABC Pediatric Therapy, LLC. I understand these Safety Guidelines, including new policies, procedures and protocols, are in addition to those already in place at the clinic.
  • I understand, agree and acknowledge that in order for a therapist at ABC Pediatric Therapy, LLC to engage with a child and provide a therapeutic environment, he or she may not be able to maintain a minimum 6’ distance from that child.
  • I understand, agree and acknowledge that in the course of receiving therapeutic services, a child may not tolerate wearing a face mask and/or tolerate a therapist wearing a face mask, and that either the child, therapist or both may have to remove their face masks in order to proceed with therapeutic services
  • I understand, agree and acknowledge that ABC Pediatric Therapy, LLC reserves the right to modify or change the COVID-19 Safety Guidelines. I also understand that a copy of any changes will be provided to me upon my written request
  • I understand, agree and acknowledge that all authorizations I have provided here will remain in effect until such time as ABC Pediatric Therapy, LLC is no longer providing treatment services to the child named herein.

Despite our careful attention to the guidelines stated above, there is still a chance that you could be exposed to an illness or COVID-19 in our clinic, just as you might be at other places in your community. By signing below, you accept the risk and consent to treatment

Parent’s/Guardian’s Signature: