Please read through the following consent forms and either email or text to confirm you have read and understood the consent form for the treatment you are booked in for and the additional covid 19 consent ..

 

Patient Consent for Treatment During COVID-19 Pandemic

 

 

I understand that I am opting for an elective treatment.

 

I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization 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.

 

I understand the Management and 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 treatment, and I give my express permission to proceed.

 

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 treatment itself.

 

I have been given the option to defer my treatment 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

 

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

 

  • Fever
  • Shortness of Breath
  • Loss of Sense of Taste or Smell
  • Dry Cough
  • Runny Nose
  • Sore Throat

 

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 14 days

 

I confirm that if I develop COVID-19 symptoms following my treatment, or a known contact of mine develops symptoms, I will immediately inform the Aesthetic Skin Clinic to enable appropriate measures to be put in place and contact tracing to commence.

 

I confirm that I understand that the usual top up follow up from any botox treatment will not be offered as standard. If you feel you absolutely need a top up after your treatment a virtual consultation will take place and a clinical decision will be made on whether it is suitable for you to reattend.

You will be expeected to wait outside until your appointment time and if you are late for your appointment you may not be able to be seen.

Please ensure you come alone to your appointment.

The waiting area, kitchen and toilet will be closed.

Please remove all makeup before your appointment if possible.

Please wear a face mask for the duration of your appointment.

 

Please email info@thewhiteroomsclinic.co.uk

 

Or text us 07936339528

to confirm you have read and understood this form and understand that you must let us know if any of the symptoms appear of have developed since your appointment .

BELOW ARE TWO CONSENT FORMS

PLEASE READ THE APPROPRIATE CONSENT FORM FOR YOUR INTENDED TREATMENT

Botulinum Toxin Consent Form

Botulinum Toxin type A is a treatment for the temporary reduction of moderate to severe lines and wrinkles in the frown area and the crows feet. Botulinum Toxin Type A may also be used in other areas for improvement in the appearance of lines and wrinkles. The effects of the procedure typically last about 3 – 5 months. The results of the initial treatment will start to become noticeable after a few days, and continue to improve for up to two weeks.

Side effects of the treatment include bruising and swelling at the injection site. Other side effects are related to the action of the Botulinum Toxin on adjacent muscles and include raising of the eyebrow, drooping of the eye brow, and drooping of the eyelid. These side effects are transitory and will last as long as the effect of the treatment.

By reading and confirming that you you have understood this form you are agreeing that you understand the nature of the proposed treatment, including alternative options, the intended benefits and potential risks. You will have the opportunity to discuss any concerns regarding your treatment at you appointment.

 

Dermal Filler Consent Form

The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the Dermal Filler Treatment. This material serves as a supplement to the discussion you have with your nurse/other healthcare professional. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your nurse/healthcare professional at your appointment.

THE TREATMENT
Treatment with dermal fillers (such as Juvederm, Restylane, Radiesse and others) can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to aging, sun exposure, illness, etc.  Facial rejuvenation can be carried out with minimal complications.  These dermal fillers are injected under the skin with a very fine needle.  This produces natural appearing volume under wrinkles and folds which are lifted up and smoothed out.  The results can often be seen immediately.  

RISKS AND COMPLICATIONS
Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list.  Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to:  1) Post treatment discomfort, swelling, redness, bruising, and discoloration; 2) Post treatment infection associated with any transcutaneous injection;  3) Allergic reaction; 4) Reactivation of herpes (cold sores); 5) Lumpiness, visible yellow or white patches; 6) Granuloma formation; 7) Localized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.  

PREGNANCY AND ALLERGIES

I am not aware that I am pregnant.  I am not trying to get pregnant.  I am not lactating (nursing). I do not have or have not had any major illnesses which would prohibit me from receiving dermal fillers.  I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine.