COVID-19 Consent Form

Please complete the form below before you visit the clinic. Please read our Social Distancing Measures page for more information.

  • I (Patient Name) understand that I am opting for an elective treatment/procedure that is not urgent and may not be medically necessary.
  • 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 also declare that I have not tested POSITIVE for COVID-19 and have not been exposed to anyone in my household or workplace that has had any of the above symptoms or tested POSITIVE in the past 14 days.
  • I declare that I am not considered vulnerable and that I am not self-isolating.
  • 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 understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organisation 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 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, even if I have been tested for COVID-19 and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID-19 after the test.
  • I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/procedure, and I give my express permission to Dr Rekha Tailor and all the staff at Health & Aesthetics to proceed.
  • 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 can lead to a higher chance of complications and death.
  • 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 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 /procedure.
  • I UNDERSTAND THE EXPLANATION AND HAVE NO MORE QUESTIONS AND CONSENT TO THE PROCEDURE.

About our Consultations

At Health & Aesthetics, we believe that the fundamental basis for a successful aesthetic procedure is an in-depth consultation with a skilled qualified practitioner to assess your needs and develop a bespoke personal treatment plan so that you achieve outstanding natural looking results. You can call us on 01252 933 133.

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