I, ____________________________, understand that I am opting for an elective treatment/surgery that is not medically urgent and is cosmetic in nature.

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 has been known to cause a range of symptoms from very minor to very severe, including death. I am also aware, the COVID-19 virus is believed to spread by person-to-person contact, and is sometimes asymptomatic (no symptoms); and, as a result, federal and state health agencies recommend social distancing and enhanced personal disinfection policies, as well as enhanced healthcare protection and disinfection policies. initial _______

I recognize that Dr. Steven C. Chang, Dr. Michael Chang and all the staff at Natural Hair Transplant Medical Center are aware of, and closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the acquisition and spread of COVID-19 at this facility. Furthermore, to aid in my own protection, I give my express permission for Dr. Steven C. Chang, Dr. Michael Chang and all the staff at Natural Hair Transplant Medical Center to implement their preventive protocols and will cooperate with those, and cover my mouth for any sneeze or coughing, use hand sanitizer liberally throughout the day and especially after touching my face especially my mouth or nose, and wear a surgical type mask at all times except while eating. However, given the nature of the virus, I understand despite these measures, there is always a risk of COVID-19 exposure when in the presence of other people, and surgery itself may reduce my immunity for infection including the postoperative period when I am healing. I hereby acknowledge and will take appropriate measures to reduce my exposure risk to COVID-19 infection during the postoperative period, and assume the risk of undergoing elective cosmetic surgery during the COVID-19 pandemic. initial _______

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 I will be asked to comply with infection control protocols, including wearing a surgical type face mask, and undergoing hand disinfection. I attest that I have been honest and thorough in sharing any risk factors I know of for COVID-19 infection. initial _______

I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time and have opted not to defer my treatment/procedure/surgery to a later date. initial _______


Patient’s Signature       /      Date