COVID-19 CONSENT

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COVID-19 CONSENT

Informed Consent and Questionnaire for COVID-19 Risk

Email *

Name *

Please enter your full name

Please check all checkboxes to confirm you understand the below COVID-19 explanation and have no more questions and consent to the treatment/procedure. *

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

I understand that the novel corona virus, 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 recognize that all the staff at Evergreen Laser Med Spa 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 Evergreen Laser Med Spa to proceed with the same.

I understand that, even if I have been tested for COVID-19 and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID-19 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 the risk of death. In addition, after my elective treatment/procedure, I may need additional care that may require me to go to an emergency room or a hospital.

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.

I confirm that I am not presenting any of the following symptoms of COVID-19 listed here: Fever, Shortness of Breath, Loss of Sense of Taste or Smell, 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 and this is not possible with massage & beautyservices.

I verify that I have not traveled within the past 14 days.

I have 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.

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A copy of your responses will be emailed to the address you provided.

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