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I understand that I am opting for an elective treatment/procedure 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 Silver Solutions MedSpa/Berkshire Wellness Associates health professionals and staff 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. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/procedure, and I give my express permission for the health professionals and staff at Silver Solutions MedSpa/Berkshire Wellness Associates to proceed with the same.
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 not have any symptoms for the same, proceeding with this elective treatment/procedure can lead to a higher chance of complication and death.
I understand that at this time, it is unclear if antibody tests and the presence of antibodies in those patients who have recovered from COVID-19 can provide protection (immunity) against getting infected again. This means that there is inconclusive information regarding the fact the antibodies make you immune to COVID-19. These test results do not confirm if you are able to spread the virus that causes COVID-19.
I understand that possible exposure to COVID-19 before/during/and after my elective treatment/procedure may result in the following: a positive COVID-19 diagnosis, extended quarantine/self isolation, additional tests, hospitalization the 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. I may need additional care that may require me to go to an emergency room or 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 elective treatment/procedure itself.
I have been given the option to defer my elective treatment/procedure 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 elective treatment/procedure.
I UNDERSTAND THE EXPLANATION AND HAVE NO MORE QUESTIONS AND CONSENT TO THE PROCEDURE.
I UNDERSTAND THAT THIS IS A LEGAL DOCUMENT AND BY SIGNING I RELEASE SILVER SOLUTIONS MEDSPA/BERKSHIRE WELLNESS ASSOCIATE, OF ALL FINANCIAL AND LEGAL OBLIGATIONS SHOULD I OR A FAMILY MEMBER, CONTRACT COVID-19 OR OTHER UNKNOWN COMPLICATIONS ARISING FROM COVID-19.
WE UNDERSTAND THAT COVID-19 IS A HIGHLY CONTAGIOUS AND POTENTIALLY DEADLY VIRUS AND WE RELEASE ALL CONSENTED PATIENTS FROM FINANCIAL AND LEGAL OBLIGATIONS SHOULD A SILVER SOLUTIONS MEDSPA/BERKSHIRE WELLNESS ASSOCIATES HEALTH PROFESSIONAL, STAFF MEMBER, OR THEIR FAMILY MEMBER, BECOME INFECTED WITH THE VIRUS IDENTIFIED THROUGH DIRECT CONTACT TRACING.
By Signing below, I acknowledge that I have read all the details in the above consent form and will receive a copy of this form in email after it is signed.
The Central Block Building
75 North Street.
Pittsfield, MA 01201Call 413.441.8453
Monday: 9:00 AM – 5:00 PM
Tuesday: 10:00 AM – 7:00 PM
Thursday: 10:00 AM – 7:00 PM
Friday: 9:00 AM – 5:00 PM