Thank you for choosing Fresh Faces Rx.

In agreeing to the waiver, I agree not to hold Fresh Faces Rx and the Fresh Faces Rx staff responsible for injuries, outcomes, or misfortunes that result from services provided.

I agree to undergoing treatment during the COVID pandemic, I agree not to hold Fresh Faces Rx or the staff responsible should I contract the virus.  I agree to contact Fresh Faces Rx in writing if I am diagnosed with COVID-19 within 14 days of my appointment. I understand that there are risks associated with being treated during a Pandemic.  I have not had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit.  I have not been diagnosed or suspected of having COVID-19 (Coronavirus).  To the best of your knowledge you have not been in close proximity to any individual who tested positive for COVID-19

COVID CONSENT TO UNDERGO TREATMENT

 

 

 

 

INFORMED CONSENT – COVID-19 PANDEMIC

 

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

I also understand that the novel coronavirus, 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 accordingly, federal and state health agencies recommend social distancing.

I recognize that the medical providers and staff at Fresh Faces Rx are closely monitoring this situation and have put in place reasonable preventive measures targeted to reduce the spread of COVID-19. Given the nature of the virus, however, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this elective treatment/procedure/surgery.

Accordingly, I acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/procedure/surgery, and I give my express permission for the medical providers and staff at Fresh Faces Rx to proceed with the same.

I understand that even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that if I have a COVID-19 infection and even if I do not have any symptoms, proceeding with this elective treatment/procedure/surgery can lead to a higher chance of complication and death.

I understand that possible exposure to COVID-19 before/during/after my treatment/procedure/surgery may result in any of 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/surgery, 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 in this Informed Consent, as well as those risks for the treatment/procedure/surgery itself.

I have been given the option to defer my treatment/procedure/surgery 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/surgery. I acknowledge that I have been offered a copy of this consent form. In addition, I agree to contact Fresh Faces Rx in writing should I be diagnosed with COVID within 14 days of my appointment.

I UNDERSTAND THE EXPLANATION AND HAVE NO ADDITIONAL QUESTIONS, I CONSENT TO UNDERGOING TREATMENTS AT FRESH FACES RX, I ASSUME RESPONSIBILITY FOR MY HEALTH AND OUTCOME.