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    I wish to be seen for a dermatologic issue(s). I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that the doctors and staff at Indigo Dermatology are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is inherent risk of becoming infected with COVID-19 by virtue of being seen in Indigo Dermatology's offices. I hereby acknowledge and assume this risk, and I give my express permission for Indigo Dermatology's doctors and staff to proceed with my upcoming visit(s).

    I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that possible exposure to COVID-19 before/during/after my upcoming visit(s) may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death.

    I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my upcoming visit(s).


    I am a parent/legal guardian of   

    When you submit, your form will be sent to a HIPAA secure account.