Designed Health Options Client Consent for Face-to-Face Visit

In view of the current COVID restrictions issued by the state government of New Mexico, we prefer not to offer face-to-face visits to protect both the staff and our clientele. However, we have been requested to provide face-to-face services by some clients who prefer to have a face-to-face visit with the provider of services. While we agree with clients as to the higher satisfaction and efficacy of a face-to-face visit, AND can accommodate this preference on the part of the client (as long as there are staff that are willing to meet in this manner) - we are happy to provide this service under the following guidelines: *

Clients MUST wear a mask in common shared areas so as not to expose other clients or staff that are not seeing the client on that visit.
The client must demonstrate his or her acceptance - of the knowledge that a physical examination will be taking place - and awareness that the proximity of this activity clearly compromises the “social distancing” rule.
Awareness and acceptance of the potential risk implied by the avoidance of 6’ minimal separation.
Acknowledgement of the potential risk of that avoidance.
Agreement to hold Designed Health Options LLC, its designees, the provider of services, and corporate entity free of responsibility from these actions.
I have read and understand the above guidelines

Contact information in the event of a question:
Trish Dawson JD, Esq
c/o Designed Health Options, LLC
P. O. Box 2480
Corrales, New Mexico 87048
drlewis@designedhealthoptions.com

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Check box if you agree with this statement

My signature below indicates that I have been given an opportunity to ask questions and have had them answered to my satisfaction. I have been made aware that a telehealth appointment may be made rather than a face-to-face visit.

Please initial below, we will print and sign this form in-person

Designed Health Options, LLC

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Calls, questions and appointments are welcomed. We’re in Corrales, 8 minutes North of Albuquerque toward Rio Rancho

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