Madfes Aesthetic Medical Center

Due to the Covid-19 outbreak, we are asking all patients that are appointed to see Dr. Madfes to cooperate with our new office protocol to ensure the safety of both our patients and staff. We greatly value your safety and therefore ask that you follow our guidelines for future in-office visits.


Prior to your appointment:

Once the forms and pictures have been received, we will use that as our appointment confirmation.

During your appointment, the following protocols will be used:
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After your appointment:


Thank you for your cooperation and patience during this time. We really appreciate it!

Best Regards,

Madfes Aesthetic Medical Center


 

COVID-19 RISK INFORMED CONSENT


I,  (patient name) understand that I am opting for an elective treatment/procedure/surgery that is not urgent and may not be medically necessary. I also understand that the novel corona virus, 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. Diane Madfes, Dr. Estee Williams, Dr. Jeannette Jakus, and all the staff at Madfes Aesthetic Medical Center 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/surgery. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/procedure/surgery, and I give my express permission for Dr. Diane Madfes, Dr. Estee Williams, Dr. Jeannette Jakus and all the staff at Madfes Aesthetic Medical Center 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 COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this elective treatment/procedure/surgery can lead to a higher chance of complication and death. I understand that possible exposure to COVID-19 before/during/after my 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 treatment/procedure/surgery, 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/procedure/surgery itself. I have been given the option to defer my 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 treatment/procedure/surgery.


INFORMED CONSENT FOR COVID-19 RISK
I UNDERSTAND THE EXPLANATION AND HAVE NO MORE QUESTIONS AND CONSENT TO THE PROCEDURE.


Signature:


Date:


I have been offered a copy of this consent form


CREDIT CARD AUTHORIZATION


I,
, give permission to the office of Dr. Diane Madfes to use the below credit card information for any current and future changes incurred on my account. This information can be filed in my records.






Signature:


Date:

 

Billing Address:




 

UPLOAD PHOTO FILES AND SKINCARE REGIMEN
 

Please upload your photos accordingly (ex: front of face, left and right side of face, areas to be treated, suspicious spots, etc.) here.
 


Please describe your current skincare regimen (face wash, moisturizer, etc.)