Covid-19 Declaration Form

Please complete this form and then press the SEND button at the end. A copy of your responses will be emailed to Toni, and a copy will be sent to the email address you provide within the form.

I understand the the COVID-19 has been declared a worldwide pandemic by the WHO and the COVID-19 is extremely contagious and is believed to spread by person to person contact and as a result, social distancing is recommended. This is not entirely possible with my proposed treatment.

However, I am satisfied that safety measures are in place to minimise risk as much as possible and patient contact will be kept to an absolute minimum in line with medical need. The Beauty Barn is closely monitoring the COVID-19 situation and has 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 the treatment. I hereby, acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment, and I give my express permission to proceed.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I understand that COVID-19 can cause additional health risks, some of which may not currently be known at this time, in addition to those risks associated with the treatment itself.

I have been given or can ask for 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.

I confirm that I am NOT suffering with any of the following symptoms of COVID-19 listed.
*required to be completed