COVID-19 Consent Form
At Ghada Y. Afifi, MD, your health and the health of our staff are of the utmost importance. To ensure your health and the health of our staff, we do follow usual universal precautions in our operatories and office. Additionally, every half hour to an hour we wipe down the waiting room and common spaces with disinfectant.
For the protection of all our patients and staff due the recent outbreak of coronavirus, we are requesting the following:
If you have an illness or are exhibiting symptoms, we recommend you cancel and reschedule your appointment. Some illness and symptoms include:
- a cold or the flu
- fever or nausea
- severe headaches or body aches
- muscle or stomach pain, chest pain or difficulty breathing
- vomiting or diarrhea
- active tuberculosis (TB)
- mumps, measles, chickenpox
- other contagious disease
Please notify our staff before your appointment if you or someone you are in close contact with have recently traveled to one of the countries with large outbreaks of COVID-19 (ex. China, Italy, Iran, South Korea) or if you have been exposed to someone else who was diagnosed with COVID-19 or who was quarantined as a precaution.
If you are healthy, there’s no need to cancel your regularly scheduled appointment.
UPDATED NEW OFFICE PROTOCOL: IN EFFECT NOW
MANDATORY COMPLIANCE FOR PATIENT AND STAFF SAFETY: We are requesting that ALL patients comply with the following guidelines that has been outlined by the CDC in order to ensure that all patients and staff are SAFE during this time of the coronavirus pandemic.
We will be reminding all scheduled patients to review theses steps BEFORE their appointment and no patient will be allowed entry to the office without confirming guideline review. THANK YOU AS WE ALL STAY SAFE!
PLEASE CALL OFFICE ON ARRIVAL 949 - 767 - 7444 or 714 - 973 - 9197 TO CHECK IN, OFFICE DOOR WILL BE LOCKED.
NO VISITORS / FRIENDS / FAMILY MAY ACCOMPANY YOU BUT YOU MAY HAVE ANY SIGNIFICANT OTHER ON YOUR CELL SPEAKER PHONE DURING A CONSULTATION OR YOU MAY REQUEST DR. AFIFI TO CALL AT END OF DAY IF ANY QUESTIONS.
ALL MUST WEAR MASK AND WE RECOMMEND GLOVES (SO CAN DISINFECT OR REMOVE AFTER YOU LEAVE)
YOU WILL NOT BE ALLOWED IN OFFICE WITHOUT MASK
- Form of payment and own pen with stylus top (DO NOT BRING PURSE / BAG or anything else or use crossbody small purse or put wallet in pocket) - we can provide pen with stylus top but then you would have to sanitize this after
- YOUR OWN HAND SANITIZER (AS WE NEED TO UTILIZE OURS FOR STAFF)
- Own gloves
- PLEASE BE PATIENT AS PACE WILL BE SLOWER IN ORDER TO DISINFECT EACH ROOM AND FOLLOW CDC GUIDELINES:
- MUST HAVE 6-7 FEET IN BETWEEN
REMINDER: THERE WILL BE NO WAITING IN THE WAITING ROOM - patients will check in via call and then be called to come in from their car - alternatively, you can wait outside in the Courtyard, spaced 6 feet apart and you will be called in when a room is ready.
- Office is disinfected daily and each examining ROOM after each use.
- We will greet you with virtual affection – this is no contact office (Dr. A WILL BE WEARING FACE SHIELD IN ADDITION TO N95 MASK AND GLOVES)
- Please maintain 6-7 feet between – you will be led to SPECIFIC EXAM ROOM.
- One of Dr. Afifi's staff members will be writing notes and giving her necessary material during the exam.
- Dr. Afifi will be the only one interacting with you in the room.
PLEASE FORGIVE US, DUE TO THE MUCH REDUCED FLOW, THE DR WILL BE UNABLE TO CONVERSE WITH YOU AS USUAL IN ORDER TO HAVE ENOUGH TIME TO TREAT PATIENTS AND AND DISINFECT THE ROOM BEFORE THE NEXT PATIENT.
She will, however, shower you with virtual affection - no contact other than actual treatment if needed.
Dr. Afifi will be dispensing a lot of virual hugs though :)
UPON CHECK OUT:
- There will be a screen between you and check out staff
- For credit card payments, you will be given opportunity to show staff your card (behind plexiglass screen) and sign with stylus.
- For cash payments: money will be allowed to be placed in plastic container, no contact needed.
- Appointments for follow up will be made at this time. We encourage you to make these appointments at this time as it might take longer when calling back.
WE RECOMMEND GENERALLY DISCARDING GLOVES UPON ARRIVAL TO CAR FROM ANY DESTINATION (groceries / doctors office / gas station)
TO AVOID CONTAMINATION.
YOU MUST WEAR NEW GLOVES BEFORE COMING TO OFFICE (office will be disinfected anyways but we are being super cautious)
If you have any questions or concerns, please contact us immediately.
The below links provide additional information regarding the coronavirus:
World Health Organization (WHO): https://www.who.int
Centers for Disease Control (CDC): https://www.cdc.gov
Our team will continue to monitor the situation and provide updated information when warranted. Thank you for your patronage.