www.noblecosmeticsurgery.com - COVID-19 Pandemic Cosmetic Treatment Consent Form

COVID-19 Pandemic Cosmetic Treatment Consent Form
Your Name*
I, {yourName} , knowingly and willingly consent to have cosmetic treatment completed during the COVID-19 pandemic. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.
I understand that due to the frequency of visits of other cosmetic patients, the characteristics of the virus, and the characteristics of cosmetic procedures, that I have an elevated risk of contracting the virus simply by being in an office of cosmetic surgery. *
(Initial)
I have been made aware of the CDC, WHO, as well as our local, state and federal government agency guidelines that are under the current pandemic.*
(Initial)
I confirm that I have not been in contact with a person that has been diagnosed with COVID-19 within the last 14 days.*
(Initial)
I understand that the CDC recommends social distancing of at least 6 feet to prevent transmission of disease and this is not possible with cosmetics. *
(Initial)
I confirm I am seeking treatment for conditions that meet these criteria.*
(Initial)
I confirm that I am not presenting any of the following symptoms of COVID-19 listed below: *
(Initial)
- Fever
- Shortness of Breath
- Dry Cough
- Runny Nose
- Sore Throat
I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. And the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has, and this is not possible with cosmetics.*
(Initial)
I verify that I have not traveled outside of the United States in the past 14 days to countries that have been affected by COVID-19.*
(Initial)
I verify that I have not traveled domestically within the United States by commercial airlines, bus, or train within the past 14 days.*
(Initial)
Signature*

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Patients Name*

First Name Last Name
Date*

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