I, —– —– (NAME, MIDDLE NAME, FAMILY NAME OF THE PATIENT) REALIZE THAT I AM BEING ON THE PLANNED (NOT ON AN EMERGENCY) OPERATION, PROCEDURE OR TREATMENT THAT CAN BE CARRIED OUT LATER AND IS NOT BASED ON MEDICAL NECESSITY.

FURTHERMORE, I REALIZE THAT THE NEW CORONA VIRUS SARS-COV2 IS A CAUSE OF THE PANDEMIC AS DECLARED BY THE WORLD HEALTH ORGANIZATION.

INFECTIOUS DISEASE – COVID19 CAUSED BY THE ABOVE MENTIONED VIRUS, IS HIGHLY CONTAGIOUS FROM HUMAN TO HUMAN AND SPREADS BY CONTACT.

I FULLY REALIZE THAT THERE IS NOT A SPECIFIC MEDICATION FOR COVID-19 TREATMENT YET. IT IS ONLY POSSIBLE TO TREAT ITS SYMPTOMS AND COMPLICATIONS.

I FULLY REALIZE THAT THE DOCTOR AND MEDICAL STAFF HAVE SITUATION UNDER CONTROL AT THE CLINIC AND DO THEIR BEST TO FOSTER THE END OF THE SPREAD OF COVID-19 WITH ALL POSSIBLE RATIONAL MEANS. NEVERTHELESS, I UNDERSTAND THAT STEMMING FROM THE NATURE OF THIS VIRUS, THERE IS A RISK OF BEING INFECTED DURING THE OPERATION, PROCEDURE OR TREATMENT.

I FULLY ACKNOWLEDGE THE RISK OF BEING INFECTED WITH COVID-19 DURING THE PLANNED OPERATION, PROCEDURE OR TREATMENT. DESPITE THE RISK OF BEING INFECTED I GIVE AUTHORITY TO MY DOCTOR AND THE STAFF OF THE CLINIC TO CONDUCT OPERATION, PROCEDURE, TREATMENT OF MY CHOICE.

I UNDERSTAND THAT I CAN BE THE SOURCE OF INFECTION DESPITE PRE-OPERATION/PROCEDURE/TREATMENT NEGATIVE TEST RESULT ON COVID-19 AND ABSENCE OF ITS SYMPTOMS.

I WILL FOLLOW MANDATORY RULES OF CONDUCT ESTABLISHED BY THE CLINIC TO CONTROL AND LIMIT THE SPREAD OF COVID-19 DURING AND AFTER THE OPERATION, PROCEDURE, TREATMENT AND CONSULTATION.

I REALIZE THAT ADDITIONAL EXAMINATIONS AND RESTRICTIONS ARE TO PROTECT ME, OTHER PATIENTS AND STAFF OF THE CLINIC FROM THE VIRUS.

I ACKNOWLEDGE THAT I AM OBLIGED TO FULLY INFORM THE CLINIC AND FOLLOW THE RULES.

I AGREE WITH DOCTOR TO CONDUCT PCR TESTING, IN THE LABORATORY LICENSED BY THE MINISTRY OF HEALTH, LABOUR AND SOCIAL AFFAIRS OF GEORGIA, 48 HOURS BEFORE THE OPERATION AND PRESENT THE RESULT FROM LABORATORY TO THE DOCTOR. PCR TESTING WILL REQUIRE ADDITIONAL FINANCIAL EXPENSES FROM ME.

I REALIZE THAT DESPITE THE NEGATIVE RESULT OF THE TESTING, THERE IS A PROBABILITY THAT TESTING MAY NOT DETECT THE VIRUS. SYMPTOMS OF THE VIRUS MAY APPEAR LATER OR I MAY GET INFECTED DURING THE TESTING PROCEDURE AS A RESULT OF CONTACTING WITH INFECTED PERSON. I ALSO REALIZE THAT ME AND THE PERSONS I AM IN TOUCH WITH MAY NEED ADDITIONAL TESTINGS AND EXAMINATIONS, THAT MAY REQUIRE ADDITIONAL FINANCIAL EXPENSES FROM ME.

I UNDERSTAND THAT BESIDES THE ABOVE MENTIONED  COMPLICATIONS AND THOSE THAT ARE TYPICAL TO THIS OPERATION/PROCEDURE/TREATMENT COVID-19 MAY POSE ADDITIONAL RISKS AND COMPLICATIONS WHICH ARE UNKNOWN AS YET.

I WAS OFFERED TO POSTPONE OPERATION/PROCEDURE/TREATMENT, BEFORE IT IS POSSIBLE TO TREAT OR PREVENT COVID-19 MORE EFFECTIVELY.

I AM NOT WILLING TO POSTPONE AND I DEFINITELY WISH THE OPERATION/PROCEDURE/TREATMENT OF MY CHOICE TO BE CONDUCTED, DESPITE THE FACT THAT I AM FULLY AWARE OF THE POTENTIAL RISKS OF SHORT AND LONG TERM COMPLICATIONS CAUSED BY COVID-19.

I FULLY COMPREHEND THE ESSENCE OF THE WARNING, I RECEIVED ANSWERS TO THE QUESTIONS OF MY INTEREST AND I GIVE MY AUTHORIZATION AND CONSENT FOR THE OPERATION/PROCEDURE/TREATMENT OF MY CHOICE TO BE CONDUCTED.

I ALSO CONFIRM THAT NOR ME NEITHER ANY PERSON LIVING WITH ME FOR LAST 14 DAYS HAVEN’T HAD AND DO NOT HAVE COVID-19 SYMPTOMS (FEVER, WEAKNESS, CAUGH, PAIN OF MUSCLES, SOAR THROAT, ETC.) TO THE BEST OF MY KNOWLEDGE, I HAVE NOT HAD CONTACTED A PERSON INFECTED WITH CORONA VIRUS, I AM NOT BEING IN QUARANTINE OR SELF ISOLATION, I MAINTAINED SOCIAL DISTANCE AND FOLLOWED ALL THE RECOMMENDED HYGIEN NORMS. NEITHER I NOR THE PERSONS LIVING WITH ME OR THE PERSONS I HAVE CONTACTED HAVE POSITIVE TEST RESULT ON COVID-19.

NAME, MIDDLE NAME, FAMILY NAME OF THE PATIENT,

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