COVID-19 – Information and Consent

Our priority at Sims IVF is always to ensure the health and safety of all our patients and staff

As the COVID-19 pandemic is still at large in our communities we have taking all precautions possible to allow ART treatments to continue in line with national regulations as well as best practice such as ESHRE guidelines. However, vigilance and measured steps must be taken for safe practice and to minimise the risks related to COVID-19.

All patients planning to start treatment will need to complete this questionnaire before commencing treatment. A further COVID-19 assessment of both partners may also be performed during ovarian stimulation.

All patients who have had a positive COVID-19 test must present medical evidence of clearance from a GP or a negative antigen test to Sims Clinic in order to be eligible for treatment or attend appointments. If patients have been on respiratory support during the COVID-19 infection episode, they should additionally provide evidence of assessment and a medical specialist report.

Which clinic are you with?

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Name

Date of Birth

Email Address

Address

Partner Name (if applicable)

Please note your partner will also have to fill out a COVID-19 form

Have you received the COVID-19 vaccine?

YesNo

If yes, date vaccine dose 1:

Date, vaccine dose 2:

Booster:

Have you been sick in the last two weeks?

YesNo

Do you have fever (37.5°C or above)?

YesNo

Do you have a cough (this can be any kind of cough, not just dry)?

YesNo

Do you have shortness of breath (breathing difficulties)?

YesNo

Do you have a sore throat?

YesNo

Have you lost your sense of smell or taste?

YesNo

Have you been in contact with somebody who has any of these symptoms?

YesNo

Do you work in a hospital/nursing home or healthcare facility?

YesNo

Have you been in contact with somebody who has COVID-19?

YesNo

Have you tested positive for Covid-19 in the past 4 weeks?
If you have selected yes, you must present medical evidence of Clearance from a GP / a negative antigen test to your treating Clinic

YesNo

Have you had a negative test since?

YesNo

If you have had COVID-19, are you symptom free now? If you are still experiencing prolonged effects of having previously tested positive e.g. dry cough, fatigue you will require GP clearance before attending the clinic for treatment.

YesNo

Do you live in a household with somebody who has been diagnosed with COVID-19 or has COVID-19 symptoms?

YesNo

Do you have a severe medical condition like heart disease, lung disease, diabetes, cancer, cerebrovascular disease, renal disease, liver disease or high blood pressure, etc.?

YesNo

Are you on any medications that may suppress or alter your immune system (e.g. steroids, hydroxychloroquine)

YesNo

Consents

I confirm that I have answered the above COVID-19 questionnaire truthfully with the best of my knowledge.

I understand that if there are any evidences that would increase the risk of COVID-19 infection the following precautions may be taken.

If I develop any of the COVID-19 symptom(s), treatment may need to be postponed for 10-14 days after symptoms disappeared or until a COVID-19 test (PCR or antigen) is performed and a negative result is available.

I understand that if I have been diagnosed with COVID-19 infection in the past 4 weeks that I may need to present medical evidence of clearance from my GP in order to be eligible for treatment and prior to attending the clinic.

I understand that if I am identified as a close contact to a positive COVID-19 case I must follow HSE guidance re isolation and antigen testing.

I consent to inform Sims IVF immediately (by phone or email) if during treatment I become aware of any new information increasing the risk of COVID-19 infection (i.e. new symptoms, being in close contact with someone who has COVID-19, etc.).

I further understand that if I have been on respiratory support during a COVID-19 infection episode, I will need to provide additional evidence of assessment and a medical specialist report.

I understand that the current evidence would indicate that Covid-19 does not appear to have an impact on fertility treatment risks or success rates. I also understand that Covid-19 does not currently appear to have an impact on pregnancies or increase the risk of complications. However, the data are extremely limited and I understand that the clinic cannot confirm that Covid-19 will have no impact on the above.

I understand that Sims IVF is taking reasonable measures to reduce the impact of transmission of Covid-19 but that undertaking treatment will affect my ability to maintain social distancing and I accept the risks of this.

Please confirm that you have read and understood the above consents and wish to proceed with treatment. This is acknowledged as a signed document, confirming that the information contained is true and accurate.

I consentI do not consent