Facial Consent for COVID-19

This patient disclosure seeks information that should be considered before making facial treatment in the circumstance of the COVID-19 virus.
Name

First Name Last Name
Birth Date

Month Day Year
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
A weak immune system can put you at greater risk for contracting COVID-19. Please select the ones that apply.

Diabetes Asthma Cancer treatment Epilepsy Heart disease Hepatitis Thyroid disease High blood pressure Endocrine disorder Other
Please disclose any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.
Have you tested positive for COVID-19?

Yes No
Have you been tested for COVID-19 and are awaiting results?

Yes No
Have you been in contact with someone who has tested positive for COVID-19?

Yes No
Have you traveled abroad by air or cruise ship in the past 14 days?

Yes No
Please select the signs or symptoms that you are currently experiencing or have experienced within the last 15 days.

Fever or above normal temparature Shortness of breath Dry cough Runny nose Reduction in your sense of smell Sore throat
Further Comments
I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.
By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Date

Month Day Year
Date
Signature

Clear
Should be Empty:

Facial Consent for COVID-19