Consent for treatments during Covid-19

Before your consultation we will ask you to read and, if you agree, sign a pre-treatment consent form regarding the potential impact of Covid-19 in relation to treatment. It's important we highlight the potential added risks of receiving aesthetics treatment, such as Botox wrinkle-smoothing injections, during this Covid-19 pandemic. To give you opportunity to think about what questions you may wish to ask, we have shown the form below.

I _______________________________________________ (patient name) understand that I am opting for an elective medical consultation/treatment/procedure.


I understand that the novel coronavirus, the World Health Organisation has declared COVID-19, a worldwide pandemic and that 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. ______ (initials)


I understand the clinical staff are closely monitoring the COVID-19 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 treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective consultation/medical treatment/procedure, and I give my express permission to proceed. _____ (initials)


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 medical consultation/ treatment/procedure itself. _____ (initials)


I have been given the option to defer my medical consultation/treatment/procedure 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 medical treatment/procedure_____ (initials)


I confirm that I am not presenting with any of the following symptoms of COVID-19 listed below:

  • Fever

  • Shortness of Breath

  • Loss of Sense of Taste or Smell

  • Dry Cough

  • Runny Nose

  • Sore Throat ___________ (Initials)


I understand that air travel significantly increases my risk of contracting and transmitting the COVID- 19 virus. I confirm that I have not travelled in the past 15 days ________ (initials)


I confirm that if I develop COVID-19 symptoms following my medical consultation/treatment/procedure or a known contact of mine develops symptoms, I will immediately inform the practitioner to enable appropriate measures to be put in place and contact tracing to commence _____ (initials)

 

I understand that follow-up treatment or review may not be possible if either my practitioner or I need to self-isolate or there are further government-imposed restrictions on travel or non-essential businesses such as aesthetics clinics.


Patient name ..........................................

Signature .............................................     

Date ....................................


Clinician name ....................................... 

Signature .............................................     

Date ....................................

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