Covid Consent Form - CosmetiCare

First Name*

Last Name*

Email*

I knowingly and willingly consent to have treatment completed during the COVID-19 pandemic. 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. Surgical and non-surgical procedures can create water spray. 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.

1. Are you aware of the CDC and State Medical Board guidelines that under the current pandemic all non-urgent procedures are not recommended? Visits should be limited to the treatment of pain, infection, conditions that significantly inhibit normal operation of the body, and issues that may cause anything listed above within the next 3-6 months.

Yes
No

2. Do you confirm that you are seeking treatment for a condition that meets these criteria?

Yes
No

3. Do you confirm that you are not presenting any of the following symptoms of COVID-19 listed below?

Yes
No

− Fever
− Shortness of Breath
− Loss of Sense of Taste or Smell
− Dry Cough
− Runny Nose
− Sore Throat

4. Do you understand that air travel significantly increases your risk of contracting and transmitting the COVID-19 virus? And the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has, and this is not possible with surgical and non-surgical procedures.

Yes
No

5. Can you verify that you have not traveled outside the United States in the past 14 days to countries that have been affected by COVID-19?

Yes
No

6. Can you verify that you have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days?

Yes
No

You have the option to sign this Agreement electronically or sign a paper copy of this Agreement. By signing electronically using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this Agreement (hereafter referred to as your 'E-Signature') is as valid as if you signed this Agreement in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and CosmetiCare.

You are also confirming that you are authorized to enter into this Agreement in your behalf. You understand that by selecting the 'Decline' button you have the option to have this Agreement made available to you in paper form for hand signing.

You acknowledge that you have access to an account with an internet service provider, and you are able to view or download a copy of the this Agreement by accessing your secure TouchMD account at https://patient.touchmd.com/ (requires the latest web browser), or by using the myTouchMD app (requires the latest iOS or Android version). You understand that a paper copy of this Agreement can also be obtained by contacting CosmetiCare at jwerhas@cosmeticare.com or by calling (949) 718-6900.

Signature for Consent*