COVID-19 Pandemic Treatment Consent Form 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 am NOT having the following symptoms. I confirm I am not having symptoms. I am having symptoms, my appointment will need to be rescheduled. • Fever • Shortness of Breath • Loss of Sense of Taste or Smell • Dry Cough • Runny Nose • Sore Throat Signature for Consent*
