Covid-19 Risk Informed Consent

Date

First Name

Last Name

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, as a result, federal and state health agencies recommend social distancing. I recognize that Dr. Tantawi and all the staff at Beauty Refined Plastic Surgery are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there Is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this elective treatment procedure/surgery. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment procedure surgery, and I give my express permission for Dr.Tantawi and all the staff at Beauty Refined Plastic Surgery 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 fall to detect the virus or I may have contracted COVID after the test. I understand that, If I have a COVID-19 Interaction, and even if I do not have any symptoms for the same, proceeding with this elective treatment procedure/surgery can lead to a higher I understand that possible exposure to COVID-19 before/during/after my treatment/procedure surgery may result in 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 herein, 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 hereby consent to communicating by call, e-mail and online with Dr. Tantawi and his staff and personnel (hereinafter referred to collectively as "my Doctor) so as to conduct virtual consultations, telemedicine/telehealth, and any other purpose deemed by my Doctor to be appropriate while I am receiving medical and aesthetic services. As announced by the US Department of Health & Human Services ("HHS") on March 17, 2020, I understand my Doctor is now authorized to use non-public facing audio and/or video communication technology to provide telehealth, whether or not related to COVID-19, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, but my Doctor is not authorized to use public facing technology, such as Facebook Live, Twitch or TikTok. I accept that even authorized non-public facing third-party applications potentially introduce privacy risks, but my Doctor will enable all available encryption and privacy modes when using these applications.

Please initial below:

I agree that my Doctor may communicate with me by Cell/Mobile Number (Calls & Texts) to the following number:

Cell/Mobile Number:

I also agree that my Doctor may communicate with me by email at the following email address:

Email:

I understand that I have the right to revoke this authorization in writing at any time, but If I do so it will have no effect on any actions taken prior to my revocation. Unless and until I revoke this authorization, it will exist in perpetuity from the date written below." I understand that I may refuse to sign this authorization and such refusal will have no effect on the medical treatment I receive from my Doctor.

I release and discharge my Doctor and all parties acting under my Doctor's license and authority from any telehealth medical privacy claims I might otherwise have had prior to HHS's March 17, 2020 notification. I certify that I have read this Authorization and Release and fully understand Its terms.

REFUND, MISSED/LATE APPOINTMENT POLICY:

At Beauty Refined Plastic Surgery we work with each client to discuss treatment objectives and review likely outcomes, benefits and risks associated with each treatment. We offer individual treatment as well as significantly discounted treatment package options so each client may choose the approach that is best suited for their needs and budget. Once services are purchased, they will not be refunded, however, to ensure our clients always receive the greatest experience at Beauty Refined Plastic Surgery, unused service values (cash equivalent for the remaining amount of a treatment package) can be applied to any other service at Beauty Refined Plastic Surgery. For Skin Care Products, all sales are final. All injectable treatment sales (Botox, Juvederm, Restylane,Sculptra etc) are final; refunds or credits cannot be offered once treatment is completed.

Results of any procedure are not guaranteed. In order to help with the best results from any procedure, it is Imperative that follow up appointments are consistently kept without interruption.

In order to provide you and every patient of Beauty Refined Plastic Surgery with the best service possible, it Is important that appointments are met on time. If you are up to 15 minutes late for a scheduled appointment for a procedure, your appointment will be rescheduled.

Missed Late Appointment Policy Missed Appointments We reserve the right to charge $50.00 for a missed appointment. To avoid this charge, patients are required to call our office to cancel their appointment, no later than 12:00 noon, on the day before the scheduled appointment. Exceptions to this policy will be taken on a case-by-case basis.

Late Appointments Patients who are 15 minutes late for their scheduled appointment will be rescheduled for another date.

I UNDERSTAND THE EXPLANATION AND HAVE NO MORE QUESTIONS AND CONSENT TO THE PROCEDURE A COPY OF THIS DOCUMENT IS TO BE GIVEN TO THE PATIENT AND ANY OTHER PERSON WHO SIGNS THIS DOCUMENT

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Last Name

Electronic Signature of Patient or Person Authorized to sign for Patient

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COVID-19 RISK INFORMED CONSENT

COVID-19 RISK INFORMED CONSENT

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