I consent to have my doctor and staff perform medical procedures, whether regarded as necessary, elective or aesthetic, during the time of the COVID-19 pandemic and after. I understand having my procedure performed at this time, despite my own efforts and those of my Doctor, may increase the risk of my exposure to COVID-19.
I have informed my Doctor of any COVID-19 testing I or any person living with me during the past 14 days has received, as well as the results of that testing, and if I am tested between now and the date of my procedure I will immediately provide results of that test to my Doctor.
I confirm neither I nor any individual living with me has any of the COVID-19 symptoms, listed by the center for Disease Control during the past 14 days has experienced any such symptoms; and that I and all persons living me for the past 14 days have practiced all personal hygiene, social distancing and other COVID-19 recommendations.