COVID Intake Form Thank you for choosing Davis Cosmetic Plastic Surgery. Please take a moment and fill out our required COVID-19 Questionnaire.We look forward to seeing you. Patient Name*Appointment Date* MM slash DD slash YYYY DCPS Staff NameHave you been diagnosed with Coronavirus?* YES NO If yes, when?*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Has anyone you live with, care for, or work with been diagnosed with Coronavirus?* YES NO If yes, when?*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you have any flu like symptoms or shortness of breath?* YES NO If Yes, please explain…*Have you traveled outside of the state or country recently (within three weeks)?* YES NO If Yes, where did you travel?*Has anyone you live with, care for, or work with traveled outside of the state or country recently? (within three weeks)?* YES NO If Yes, please explain…*Are you directly caring for anyone elderly?* YES NO Patient TemperaturePatient Has MaskHand Sanitizer at DoorHas any of the above information changed?* YES NO If yes, what information?*Patient Signature*Date* MM slash DD slash YYYY DCPS Staff SignatureDate MM slash DD slash YYYY COVID-19 RISK INFORMED CONSENTConsent*I understand that I am opting for an elective appointment/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. Steven Davis, and the staff at Davis Cosmetic 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 appointment/treatment/procedure/surgery. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective appointment/treatment/procedure/surgery, and I give my express permission for Dr. Steven Davis and the staff at Davis Cosmetic Plastic Surgery to proceed with the same. I acknowledge & have read the above paragraph*Consent*I understand that, even if I have been tested for COVID-19 and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID-19 after the test. I understand that, if I have a COVID-19 infection, and even if I do have any symptoms for the same, proceeding with this elective appointment/treatment/procedure/surgery can lead to a higher chance of complication and death. I acknowledge & have read the above paragraph*Consent*I understand that possible exposure to COVID-19 before/during/after my appointment/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 appointment/treatment/procedure/surgery, I may need additional care that may require me to go to an emergency room or hospital. I acknowledge & have read the above paragraph*Consent*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 appointment/treatment/procedure/surgery itself. I acknowledge & have read the above paragraph*Consent*I have been given the option to defer my appointment/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 appointment/treatment/procedure/surgery. I acknowledge & have read the above paragraph*Patient Signature*Date* Month Day Year DCPS Witness