Nassau Queens Medical Care PLLC
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Nassau Queens Medical Care PLLC
Specializing in Federal Workers' Compensation
Our location
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75-35 31st Avenue, Suite 205
East Elmhurst, NY 11370
   Tel: 718-316-6870

COVID-19 DISCLOSURE, ASSUMPTION OF RISK AND WAIVER OF LIABLITY

Please, read the entire form very carefully, and answer all 4 questions in it!

I, the undersigned individual, desire to receive therapy services from Nassau Queens Medical Care PLLC ("NQMC"). I understand and agree that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization and that COVID-19 is extremely contagious and is believed to be spread mainly from person-to-person contact.

I understand and agree that despite the preventive measures put in place by NQMC, my presence at NQMC's facilities and therapy services received by me from NQMC shall be at my own risk relative to contracting COVID-19. NQMC, including its agents and employees, make no promises or assurances concerning anyone's or anything's health, safety, or well-being before, during or after the rendering of any therapy services.

By signing below, I agree to take any and all reasonable precautions to safeguard myself and others from being exposed to, contracting, or spreading COVID-19 including all of the following:
  1. I am aware of and will comply with all federal, state and local laws and orders currently in effect, from time to time, related to COVID-19.
  2. I am aware of NQMC's guidelines related to COVID-19 and I will comply with them. For NQMC's guidelines related to COVID-19 click here.
  3. I understand that I am responsible for exercising reasonable care to protect myself including, but not limited to: assessing my own risks based on among other things, my age, underlying health conditions, past travel, past potential exposure, doctor's recommendations, and CDC recommendations.
  4. I believe to the best of my knowledge and represent to NQMC that I am not currently sick, and I do not have a fever, persistent cough, shortness of breath, or other COVID-19 symptoms.
  5. I believe that I am unlikely to transmit or contract COVID-19, coronavirus, or any other communicable disease.
  6. I am not under a direction by any medical provider or governmental representative to be under quarantine.
  7. I have truthfully answered the COVID-19 questionnaire contained herein.
  8. I agree that if any one of the answers, which I provided in this form, shall change, I will immediately stop receiving any therapy services at NQMC and avoid being on NQMC premises, and I will immediately inform NQMC staff and Doctor Deborah Eisen of all these changes - both orally and by resubmitting this form, and after that I will wait for Doctor Eisen's written approval before returning to NQMC premises or getting any further therapy services there.
  9. I will wash my hands with soap immediately upon entering the NQMC facility at any designated area provided, and/or use a hand sanitizer if available and will not touch my eyes, nose, or mouth.
  10. I will wear a mask at all times during which I am present at NQMC facilities.
  11. I will practice social distancing by keeping a distance of at least 6 feet from any other person (with the exception of any persons performing therapy services).
  12. I will avoid touching, standing close to, or leaning against anyone or anything.
  13. I am aware of and following Matilda's Law which adds additional guidance for persons over the age of 70, those with compromised immune systems and those with underlying health conditions.

COVID-19 QUESTIONNAIRE - 4 QUESTIONS

If the answer to any of these questions is YES, you cannot come to NQMC premises or recieve any therapy there without a prior written approval from Doctor Deborah Eisen.


1) Have you come in close contact (within 6 feet) with someone who has a laboratory confirmed COVID-19 diagnosis in the past 14 days?
2) Are you currently under any mandated self-quarantine order?
3) Do you have a fever (greater than 100.4 F or 38.00 C) OR symptoms of lower respiratory illness such as cough, shortness of breath, difficulty breathing, or sore throat?
4) Does Matilda's Law apply to you? (Matilda's Law applies to persons over 70 years of age and/or persons with a compromised immune system and/or persons with an underlying health condition).


By signing below, I agree to follow the above-stated protocol and acknowledge and agree: (i) that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including NQMC employees, staff and other patients; (ii) that exposure to or infection by COVID-19 may result in personal injury, illness, permanent disability and death; (iii) that I voluntarily exclusively assume all risk that I may be exposed to or infected by COVID-19 by my presence at the NQMC facility or by receiving therapy services at NQMC; (iv) that I hereby release and hold NQMC, its employees, agents and representatives, harmless from any and all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating to exposure to or infection by COVID-19 regardless of whether any such claims arise from or are based on the actions, omissions, or negligence of NQMC, its employees, agents and representatives; and (v) that I shall indemnify NQMC for any damages, costs, attorneys fees', and/or fines from any third party, that arise from my failure to follow the above-stated protocol or otherwise arise from my actions, omissions, or negligence related to exposure to or infection by COVID-19.

Patient's first name (required):

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Patient's phone number (required):

Date of signature (required):

Patient's signature (required - use mouse or touchscreen to sign):