I,________________________ (patient name) understand that I am opting for an elective treatment/ procedure that is not urgent and may not be medically necessary.

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 • I understand that COVID-19 is believed to be spread by person-to-person contact and, as a result, federal and state health agencies recommend social distancing. However, I understand that physical distancing of 6 feet is not possible while receiving treatments from Aikana Esthetic Center (Pur Beauty LLC).

• I understand that I must sanitize my hands before entering Aikana Esthetic Center, (Pur Beauty LLC.) and I must wear a mask that covers my mouth and nose while in common areas. Please read ALL the following statements and initial all the statements that apply to you:

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    ▪______ I confirm that I am not currently positive for the novel coronavirus and I am not waiting for the results of a laboratory test for the novel coronavirus.

    ▪ ______I verify that I have not traveled outside of D.C, Maryland, Virginia  by air, cruise ship, car, bus, or train in the past 14 days.

    ▪ ______I verify that I have not been identified as a contact of someone who has tested positive for the novel coronavirus or been asked to self-isolate by health care providers, the Communicable Disease Control or any other government agency

   ▪______ I confirm that I am not presenting with any of the following symptoms of COVID-19: o Fever > 38°C/99.5F o Flu-like symptoms: Cough, Sore Throat, Chills o Shortness of Breath; Difficulty Breathing

    ▪ ______I confirm that I am not in a high risk category for increased illness or death from COVID-19, including: diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised (including transplant recipient), having active malignancy, or over the age of 65.

   ▪______ I understand that I may be unable to proceed with certain procedures From Pur Beauty LLC if the procedures are deemed unsafe to myself or a staff member.

   ▪ ______I understand that I may NOT bring family members– including children, friends, pets and/or any other individuals, Aikana Esthetic Center, if they do not have an appointment.

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 • I understand that the staff Aikana Esthetic Center (Pur Beauty LLC) will do everything possible to minimize the spread of COVID-19 by wiping all hard surfaces, such as door handles, iPads, payment terminals, and counter tops before, in-between and after each patient, and thus, they cannot be held responsible should I contract COVID-19.

• I will immediately Contact Aikana Esthetic Center (Pur Beauty LLC), if I contract the virus within two weeks following my visit. I verify the information I have provided on this form is truthful and accurate.

 

Patient Name: ___________ DOB: ___________

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 Patient Signature: ___________________Date:________