COVID 19 In-Home Consult Consent Form

I, (insert first and last name below), declined a virtual consult and knowingly and willingly consent to an in-home consult with Infant Basics and Toddler Training during the COVID-19 pandemic.(required)

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 my consultant at Infant Basics and Toddler Training has 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 an inherent risk of becoming infected with COVID-19 by virtue of proceeding with the in-home consult for myself and everyone who will be present during the in-home consult, including my child. I hereby acknowledge and assume the risk of myself and my child becoming infected with COVID-19 through this in-home consult, and I give my express permission for my consultant at Infant Basics and Toddler Training to proceed with the same. (initial below)(required)

I understand that possible exposure to COVID-19 before/during/after the in-home consult may result in the following to me, my child and everyone who will be present during the in-home consult: 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. (initial below)(required)

I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time. (initial below)(required)

I have been given the option to defer my in-home consult and instead do a virtual consult. However, I understand the 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 the in-home consult. (initial below)(required)

Please include below everyone who will be present for the in-home consult (first and last name). All adults and guardians of child(ren) must each sign the COVID 19 In-Home Consult Consent Form.(required)

To prevent the spread of contagious viruses and to help protect each other, I understand that during the in-home consult I will follow Infant Basics and Toddler Training's strict guidelines in line with the CDC: wear a mask, wash hands often, practice social distancing by maintaining 6 feet away from each other when appropriate, and monitor my health. The morning of the in-home consult by 9am, I will fill out Infant Basics and Toddler Training's Monitor My Health Form. (initial below)(required)

I give permission for the consultant at Infant Basics and Toddler Training to perform basic baby care with my child, including, but not limited to: Bottle Feeding, Nail Clipping, Nasal Suctioning, Rectal Temperature, Bath, and Swaddling. (initial below)(required)

By signing your first and last name below, you agree to the COVID 19 In-Home Consult Consent Form listed above. *Client/Guardian eSiganture Below*(required)

Date(required)

Email(required)

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