COVID Consent Form - CosmetiCare

First Name*
Last Name*
Email*
Mobile # **
1. I knowingly and willingly consent to have treatment completed during the COVID-19 pandemic.
- Yes
- No
2. 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.
- Yes
- No
3. I understand that surgical and non-surgical procedures can create water spray. I understand that it is unclear as to how long the ultra-fine nature of the spray may linger in the air, which can transmit the COVID-19 virus.
- Yes
- No
4. I understand that in accordance with current CDC and CDPH requirements, I will wear a mask for the safety of other patients and office staff, regardless of vaccination status.
- Yes
- No
5. I understand that CosmetiCare will continue to monitor temperatures for ALL patients, regardless of vaccination status as an added safety precaution.
- Yes
- No
6. I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:
• Fever
• Shortness of Breath
• Loss of Sense of Taste or Smell
• Dry Cough
• Runny Nose
• Sore Throat
I confirm that I am not presenting any symptoms of COVID-19.
- Confirmed
- Not Confirmed
Signature for Consent*

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Preferred Appointment Date

Surgery Interest Timeline(Required)

Preferred Contact Method(Required)

Preferred Contact Time(Required)

Desired Treatment

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Preferred Appointment Date

Surgery Interest Timeline(Required)

Preferred Contact Method(Required)

Preferred Contact Time(Required)

Desired Treatment

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Preferred Appointment Date

Surgery Interest Timeline(Required)

Preferred Contact Method(Required)

Preferred Contact Time(Required)

Desired Treatment

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Preferred Appointment Date

Surgery Interest Timeline(Required)

Preferred Contact Method(Required)

Preferred Contact Time(Required)

Desired Treatment

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Preferred Appointment Date

Surgery Interest Timeline(Required)

Preferred Contact Method(Required)

Preferred Contact Time(Required)

Desired Treatment

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Preferred Appointment Date

Surgery Interest Timeline(Required)

Preferred Contact Method(Required)

Preferred Contact Time(Required)

Desired Treatment

First Name*
Last Name*
Phone*
Email*
Preferred Appointment Date
MM slash DD slash YYYY
Surgery Interest Timeline*
Preferred Contact Method*
Preferred Contact Time*

First Name*
Last Name*
Phone*
Email*
Desired Treatment*
Surgery Interest Timeline*
By submitting this form, I agree to authorize contact by CosmetiCare to discuss their services with me at the telephone number provided. *Consultation fees are applicable for new Dr. Niccole and Dr. Von Maur patients ($150) and Bio Identical Hormone Therapy ($285).
Phone
This field is for validation purposes and should be left unchanged.