Covid 19 Consent for Treatment | Naked Face Spa LLC

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Covid-19 Consent For Treatment
To proceed with receiving care, I confirm and understand the following

l understand that the novel Coronavirus(COVID-19) has been declared a global pandemic by the World Health Organization (WHO).I further understand that COVID-19 is extremely contagious and may be contracted from various sources.I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

I understand that I am the decision maker for my health care. To the best of their ability , my practitioner will provide me with information to assit me in making informed choices.

This process is often referred to as "informed consent" and involves my understanding and agreement regarding recommended care , and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing , I understand determing who is infected with COVID-19 is exceptionally difficult.

I understand that preventative measure and intensified sanitation protocols intended to reduce the spread of covid-19 have been implemented. However,because this work involves close physical proximity over an extended period of time in a closed space,there may be an elevated risk of diseases transmission, including Covid-19. care.

I hereby acknowledge and assume the risk of becoming infected with Covid-19 through this treatment and give my express permission to you and the staff at your offices to proceed with providing

I have been offered a copy of this consent form

I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION.

I HAVE READ,OR HAVE HAD READ TO ME,THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTION ABOUT ITS CONTENT,AND BY SIGNING BELOW,I AGREE WITH THE CURRENT OF FUTURE RECOMMENDATION TO RECEIVE CARE AS ITS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE, I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FROM ALL PROVIDERS IN THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION[S] FOR WHICH I SEEK CARE FROM THIS OFFICE.

SIGNATURE

Date

Parent or Guardian Signature{in case of a minor}

Date

Client Name

Date

COVID-19 information

1.Have you had a fever in last 24 hours of 100°F or above

Yes

No

2.Do you now, or have you recently had, any respiratory or flu symptoms,sore throat,or shortness of breath?

Yes

No

3. Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has coronavirus type symptoms?

Yes

No

COVID-19 is a highly contagious virus that spreads from a person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventative measures have been put in place to further reduce the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected.

Consent for treatment:

I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission,including COVID-19,by signing this form,i acknowledge that i am aware of the risk involved from receiving treatment at this time, i voluntarily agree to assume those risks, and i release and hold harmless this practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.

Client Signature

Date

Parent or Guardian Signature{in case of a minor}

Date

Thanks for submitting!

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