Consent and Questionnaire

ATLANTIS DAY SPA
#301 1777 56th Street
Tsawwassen BC. V4L 0A6
604-948-0458

CONSENT FOR COVID-19 RISK INFORMED CONSENT

I understand that I am opting for an elective treatment that is not urgent and may not be 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 Judy Drew, Christy Oleskiw and all the staff at Atlantis Day Spa 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.

I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment, and I give my express permission for Judy Drew, Christy Oleskiw and all the staff at Atlantis Day Spa 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 fail to detect the virus or I may have contracted COVID after the test. I understand that, if I have a COVDI-19 infection, and even if I do not have any symptoms for the same, proceeding with this elective treatment can lead to a higher chance of complication and death.

I understand that possible exposure to COVID-19 before /during /after my treatment 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, 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 itself.

I have been given the option to defer my treatment 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.

COVID-19 SCREENING QUESTIONNAIRE

We value the health of you, ourselves, and your family. That’s why we just need to be informed if you are experiencing symptoms of COVID-19. Once you complete this form, please advise us if you answered “yes” to any questions. All information captured on this form is kept confidential and your privacy is assured.

1) Are you experiencing any of the following:
• Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)
• Severe chest pain
• Having a very hard time waking up
• Feeling confused
• Losing consciousness
2) Are you experiencing any of the following:
• Mild to moderate shortness of breath
• Inability to lie down because of difficulty breathing
• Chronic health conditions that you are having difficulty managing because of difficulty breathing
3) Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones?
Symptoms include: fever, chills, cough, shortness of breath, sore throat and painful swallowing, stuffy or runny nose, loss of sense of smell, headache, muscle aches, fatigue or loss of appetite.
4) Have you travelled to any countries outside Canada (including the United States) within the last 14 days?
5) Did you provide care or have close contact with a person with confirmed COVID-19?
Note: This means you would have been contacted by your health authority’s public health team.

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