Form
Client Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Phone Number
*
-
+44
Phone Number
Email
*
example@example.com
Have you or have you been in contact with anyone who has been diagnosed with COVID-19 in the last 14 days?
*
YES
NO
Have you experienced any cold or flu-like symptoms in the last 14 days?
*
YES
NO
Do you have a new continuous cough?
*
YES
NO
Do you have a high temperature (fever)?
*
YES
NO
If you don't have a thermometer, do you feel hot to the touch on your chest or back?
*
YES
NO
Do you have a sore throat, a tacky throat or soreness when swallowing food?
*
YES
NO
Have you experienced loss of taste and smell?
*
YES
NO
Consent
I understand that I am opting for an elective medical treatment. I understand the novel Coronavirus, COVID-19, has been declared a worldwide pandemic by the WHO and that COVID-19 is extremely contagious and is believed to be 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 also understand that although measures are in place, there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with treatment. I hearby acknowledge and assume the risk of becoming infected with COVID-19 through this elective medical treatment and I give my express permission to proceed. I confirm that if I develop any symptoms following my treatment, or a known contact of mine develops symptoms, I will immediately inform the clinic to enable appropriate measures to be put in place and contact tracing to commence.
Signature
Clear
Date
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Month
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Day
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Date
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