We are 100% committed to the health and well-being for everyone. We are doing everything we can to keep potential exposure out of our office.

As part of the local and state guidelines you must answer no to all the following questions each time you enter Pua Manu Medspa.

• Not present a fever over 100 F/ 37 C.
• Not presenting cold, cough, difficulty breathing muscle pain, headache
• Loss of taste/smell or pink eye in past 14 days.
• Not in contact with anyone with these symptoms in the past 14 days.
• Not been off island and returned without being quarantined for 14 days.
• Not in contact with anyone diagnosed with COVID-19, sick and quarantined, in the past 14 days.

All information above is true. I may be asked again when I arrive for my appointment. 
ALL PATIENTS AND STAFF ARE REQUIRED TO: 

• Please follow our local and state regulations and guidelines, including those related to occupancy levels, social distancing and other measures intended to reduce the spread of viruses.
• Stay home if you are sick or are exhibiting symptoms of illness such as a fever or persistent cough.
• Face mask are required to enter the Spa.
• Refrain from shaking hands or other touching rituals.
• Wash hands for 60 seconds with soap and warm water prior to treatment or use hand sanitizer.
• Refrain from eating or drinking while in the Spa, face mask should not be removed. 

I agree to comply to the rules listed above.

 

I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact, and as a result, federal and state health agencies recommend social distancing. I understand that Pua Manu Medspa has put in place reasonable safety measures to help reduce the spread of COVID-19.

I understand that COVID-19 may cause additional risks, some of which may not be known at this time.

I understand that I am consenting to an elective treatment/procedure that is not urgent or emergent. I understand that it may put me at increased risk for becoming infected with COVID-19, due to potential community exposure.

PATIENT’S ACCEPTANCE OF RISKS

By signing this consent form I accept the risks described above and give my permission to proceed with the treatment/procedure.

I have read this consent or someone has read it to me and want to proceed.

Lesion Excision Consent Form
You have the right and obligation to make decisions concerning your health care. Your doctor can provide you with the necessary information and advice, but because this affects you, you must enter into the decision-making process. This form has been designed to acknowledge your acceptance of treatment by your doctor. Please feel free to ask any questions.

1) I hereby authorize NANCY CHEN, M.D. (and any associate or assistant involved in my care) to treat the following condition(s) which has (have) been explained to me. PROFESSIONAL: Cystic Lesion ORDINARY OR LAY LANGUAGE: Lump

2) The procedure(s) planned for treatment of my condition(s) has (have) been explained to me by my doctor as follows: PROFESSIONAL: Excision of the Cystic Lesion ORDINARY OR LAY LANGUAGE: Surgical Excision of Cystic Lesion

3) I recognize that, during the course of the operation, post-operative care, medical treatment, anesthesia, or other procedure, unforeseen conditions may necessitate my above-named doctor, and her assistants, to perform such surgical or other procedures as are necessary to preserve my life or bodily function.

4) I have been informed that there are many significant risks, such as sever loss of blood, cardiac arrest, and other consequences that can lead to death or permanent or partial disability, which can result from any procedure.

5) No promise or guarantee has been made to me as a result or cure.

6) I consent to the administration of (general, regional, local) anesthesia by an anesthesiologist, by my attending physician, or by other qualified individual under the direction of a physician as may be deemed necessary. I understand that all anesthetics involve risks that may result in complications and possible serious damage to such vital organs as the brain, heart, lungs, liver and kidney. These complications may result in paralysis, cardiac arrest and related consequences or death from both known and unknown causes.

7) Any tissues or parts surgically removed may be disposed of by the center or doctor in accordance with accustomed practice.

8) I consent to the photographing, videotaping, televising, or other audio and/or visual recording of this operation, postoperative care, medical treatment, anesthesia, or other procedures for medical or scientific purposes or for the purpose of advancing medical education, provided my identity is not revealed by the pictures, by the recording or by the descriptive texts accompanying them.

9) Also, for the purpose of advancing medical education, I consent to the admittance of observers to the operating room, during my postoperative care, medical treatment anesthesia or other procedures.

10) Additional comments: ____________________________________________________________

11) I have had the opportunity to ask questions about this form.

I AGREE THAT MY PHYSICIAN HAS INFORMED ME OF THE:

a) Diagnosis or probable diagnosis

b) Nature of the treatment or procedures recommended

c) Risks or complications involved in such treatment or procedures

d) Alternative forms of treatment, including non-treatment, available

e) Anticipated results of the treatment

Discounted or special priced treatments must be prepaid in full by first treatment appointment. Incomplete and/or cancelled treatments will be charged at regular/full price, NO refunds. I understand that necessary photos will be taken before, during and after the course of my treatments for medical purposes and to evaluate treatment effectiveness. I understand that my photos will be kept confidential in my electronic patient record.

consent to photographs and other audio-visual and graphic materials before, during and after the course of my treatments to be used for marketing and medical educational purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I may or may not be identified by the photos.