Covid-19 | Leanne Marie Clinica

Covid-19 Health Declaration

Pre-appointment completion required.

First Name

Last Name

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing any symptoms: fever, cough, sore throat, loss of taste or smell

I haven’t been in close contact or living with a Covid-19 patient, any one showing symptoms or self-isolating in the last 14 days

Are you pregnant, over 70, or suffer from any of the following: Diabetes, cardiovascular disease, including hypertension, chronic lung disease, immunodeficiency, cancer under active treatment?

Initials

Date

Instructions when attending your appointment

Attend your appointment unaccompanied.
Upon arrival, you must wash your hands.
Please limit the wearing of jewelry. Wedding rings may be worn provided hands are kept clear from the face. Minimal make-up should be worn.
Please limit the personal possessions you bring with you. The clinic may reserve the right to prevent personal items entering the treatment rooms.
When the treatment is complete, you must wash your hands once more.
Follow the markings in the waiting area and clinic to ensure 2 metres distancing at all times, except when undergoing treatment.

Additional Patient Consent for Treatment During COVID-19 Pandemic - PLEASE READ

I understand that I am opting for an elective medical consultation/treatment/procedure. I understand that the novel coronavirus, the World Health Organization 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.

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 consultation/medical treatment/procedure, 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 medical consultation/ treatment/procedure itself.

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.

Should any complication described in consenting process arise and a lock down is enforced, face to face consultations will not be possible and any assessment, management and support can only be provided by telephone or video call, remotely. Corrective procedures will not be possible until lockdown is released. If this risk is unacceptable, then you should not proceed. No refunds or financial compensation can be offered for circumstances beyond our control. By agreeing to this a treatment you are accepting these risks and terms.

I understand that air travel significantly increases my risk of contracting and transmitting the COVID19 virus. I confirm that I have not travelled in the past 15 days

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

There is increasing evidence that dermal fillers given in the presence of a recent viral infection (or where a virus is caught after treatment) can increase the risk of delayed hypersensitivity reactions. Whilst dermal fillers do not impact risk of contracting or recovery from any viral infection, there is some evidence to suggest viral or bacterial infections can trigger immunogenic reactions in the implants, which may be delayed. Should this complication arise, management may be challenging as steroids cannot be used, and should lock down recur, face to face treatment such as Hyalase™ (hyaluronidase) cannot be administered.

I declare that the information I’ve provided is accurate & complete

Thanks for submitting!