I 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 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 Dr. Arnold Panzer, M.D., Heather Hurd, R.P.A.-C. and all the staff at Long Island Medical Services 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. Arnold Panzer, M.D., Heather Hurd, R.P.A.-C and all the staff at Long Island Medical Services 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.


I understand I will not enter this office for treatment if I have a fever, sore throat, cough, shortness of breath or any other respiratory symptoms or diarrhea or history of vomiting 

I understand in order to keep my appointment I must come to the office with a mask on no makeup and my hair back.





Based upon case reports regarding having a dermal filler treatment within a certain time frame of receiving the SARS-CoV-2 mRNA vaccine, side effects may occur.  A new guidance from the American Society for Dermatologic Surgery (ASDS) has been released regarding these side effects, if they should in fact occur.


In the guidance, the FDA data reports show three participants out of 15,184 who received at least one dose of Moderna's mRNA-1273 vaccine have developed lip or facial swelling in areas of dermal filler placement, while no participants in the placebo group experienced any filler- related adverse events.


 Current ASDS guidance regarding dermal fillers and the vaccine are as follows:


-Dermal filler inflammatory events very seldom occur with both hyaluronic acid      and non -hyaluronic acid (calcium) fillers.


–Evidence suggests these reactions can be immunologically triggered by viral and bacterial illness, vaccinations, and dental procedures.


–These are RARE and TEMPORARY ADVERSE EVENTS and respond to treatments such as oral corticosteroids, and often resolve without treatment.


–Patients already treated with dermal fillers should not be discouraged or precluded from receiving vaccines of any kind.  Patients who have had vaccines should not be precluded from receiving dermal fillers in the future.


–With the guidelines reported, a 2-3 week waiting period after a vaccination, bacterial/ viral illness, or dental procedure.

I agree to these terms and conditions and take responsibility for any side effects that may occur. I also will let Dr. Arnold Panzer, M.D., and Heather Hurd, R.P.A.-C. know if I plan on or had the SARS-CoV-2 mRNA vaccine. 

Thanks for submitting!