Skip to content
Healthy skin from the inside out
Home
About
Services
BOOK NOW
Gallery
Forms
TKR Waiver
Glowgirl COVID-19 Consent for Treatment
Skincare Consultation Questionnaire
Contact me
0
0
Menu
Close
Home
About
Services
BOOK NOW
Gallery
Forms
TKR Waiver
Glowgirl COVID-19 Consent for Treatment
Skincare Consultation Questionnaire
Contact me
0
Home
Services
Contact me
About/TKR WAIVER
Book
Shop products
TKR Waiver
Skincare Consultation Questionnaire
COVID-19 Consent for Treatment
Blog
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Date / Time
Date
Time
Email
*
Phone
To proceed with receiving care,I confirm and understand the following. I understand that COVID -19 has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID -19 is extremely contagious and may be contacted from various sources. I understand COVID -19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.
*
Yes, I understand the statement above
No, I do not understand
I understand that I am the decision maker for my health care. To the best of their ability, my practitioner will provide me with information to assist me in making informed choices. This process is often referred to as "informed consent" and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health careduring a pandemic. Given the current limitations of COVID -19 virus testing, I understand determining who is infected with COVID -19 is exceptionally difficult.
*
Yes, I agree and understand the above statement to be true
No, I do not agree or understand this statement
I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID -19 have been implemented. However, because this work involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID -19. I hereby acknowledge and assume the risk of becoming infected with COVID -19 through this treatment and give my express permission to you and the staff at your offices to proceed with providing care.
*
Yes, I agree and understand the above statement to be true
No, I do not agree
I understand I may ask for a hard copy of this form ,or print a copy myself.
*
Yes,I understand the statement but do not require a hard copy.
Yes, I understand and would like a hard copy
No, I do not understand
I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID -19 PANDEMIC.
*
Yes, I agree with the above statement
No, I do not agree
I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION.
*
Yes
No
I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID -19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD THE OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT ,AND BY SIGNING BELOW (OR CHECKING THE YES BOX) I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FROM ALL PROVIDERS IN THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE.
*
Yes, I agree with the above statement
No
Signature (if completing this in person).
Date / Time
*
Date
Time
Parent or Guardian consent (in case of minor).
*
Yes
No
Not applicable
I consent to receiving emails from Glowgirl Skincare ( we respect your privacy).
*
Yes
No
Please click the button below to submit
Submit
×
