I, understand that I am opting for an elective treatment/procedure that is not urgent and may not be medically necessary.

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 provincial health agencies recommend social distancing. I recognize that all the staff at BeneFacial by Doris D. are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this elective treatment/procedure.

I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/procedure, and I give my express permission for all the staff at BeneFacial by Doris D. to proceed with the same.

I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that, if I have a COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this elective treatment/procedure can lead to a higher chance of complication and death.

I understand that possible exposure to COVID-19 before/during/after my treatment/procedure may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and

I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the treatment/procedure itself.

Ihave been given the option to defer my treatment/procedure to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired treatment/procedure.

I UNDERSTAND THE EXPLANATION, HAVE NO MORE QUESTIONS, AND CONSENT TO THE PROCEDURE.

2338 Major Mackenzie Drive, Unit 2 Vaughan, Ontario, L6A 3Y7

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our employees and visitors, we are conducting a simple screening questionnaire.  Your participation is important to help us take precautionary measures to protect you and everyone in this area.  Thank you for your time.

I CERTIFY THAT ABOVE DECLARATION IS TRUE AND ANY DISHONEST ANSWERS MAY HAVE SERIOUS PUBLIC HEALTH IMPLICATIONS.

I UNDERSTAND THE EXPLANATION,  I HAVE NO MORE QUESTIONS.