Online New Patient Paperwork


Patient Information







Medical History

Past Medical History

Do you have or have you had any of the following? Please select all that apply



Past Surgical History

If yes, please list:



Medications

List all medicines and supplements you take


Allergies

I certify that the above is true, correct, and complete. I am aware and accept that withholding information about my medical history could result in serious injury to me harm to those involved in my care


COVID-19 RISK INFORMED CONSENT

I, * understand that I am opting for an elective consultation/ treatment/procedure/surgery that is not urgent and may not be medically necessary. I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Heath 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 Dr. Gustavo Galante and his staff at Gustavo E. Galante, M.D. 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 an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this elective treatment/procedure/surgery. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/ procedure/surgery and I give my express permission for Dr. Gustavo Galante and his staff at Gustavo E. Galante M.D., to proceed with the same.

I understand that, even if I have been tested for COVID and received a negative test result, the test in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that if I have a COVID-19 infection, and even if I do not have symptoms for the same, proceeding with this elective treatment/procedure/surgery can lead to a higher chance of complication and death.

I understand that possible exposure to COVID-19 before/during/after my treatment/procedure/surgery 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. In addition, after my elective treatment/procedure/surgery, I may need additional care that may require me to go to an emergency room or a hospital.

I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risk described herein, as well as those risks for the treatment/procedure/surgery itself.

I have been given the option to defer my treatment/procedure/surgery to a later date. However, 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 desired treatment/procedure/surgery.

I UNDERSTAND THE EXPLANATION AND HAVE NO MORE QUESTIONS AND CONSENT TO THE PROCEDURE. I VERIFY THAT MY TYPED IN SIGNATURE BELOW SERVES AS MY WRITTEN SIGNATURE.

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