INFORMED CONSENT ABOUT COVID-19 RISK

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Patient name: [PatientFirstName] [PatientLastName]

Date of birth: [PatientDoBShort]

Address: [PatientAddr1], [PatientAddr2], [PatientAddr3] ,[PatientPostcode]

Clinic details: MACS CLINIC, Unit 3 Wilmington Close Watford WD18 0AF

I , [PatientName] , understand and accept the following. I have been given time to consider the information within this document and give my consent to undergo surgery considering the risks of COVID-19.

INITIALS: ___________________

• I understand, from my surgeon and clinic, that I am undergoing an elective surgical procedure through my own choice.
• I understand that COVID-19 is an infectious disease that has been declared a worldwide pandemic by the World Health Organisation and is associated with death in some people.
• I understand there is a risk that I can catch COVID-19 before, during or after the time of surgery
• If I suffer from COVID-19 I accept that it can be impossible to determine the contagious source of the disease
• I understand that even if I have been tested for Coronavirus and received a negative test, the results in some cases fail to detect the virus. I also accept I can contract COVID-19 after a test has been performed.
• I understand that if I suffer from COVID-19 after surgery, there might be a higher risk of death and suffering from the disease

• I understand that contracting COVID-19 may result in the following; extended quarantine/self-isolation, additional tests, hospitalisation that may require medical therapy, intensive care therapy, intubation/ventilator support, increased complications for the treatment I am having, and other potential complications associated with COVID-19 treatment.
• I understand that COVID-19 is a new disease and there may be additional risks that are currently unknown and that it is not possible to quantify the risk of complications right now.
• I have been given the option to defer my treatment to a later date, I have been given the option to cancel my treatment and I would like to proceed with my desired treatment in full knowledge of the risks in this consent form.
• I agree that if I develop symptoms, have contact with anyone or have been tested for coronavirus then I will inform my surgeon.
• I agree that if I develop COVID-19 and suffer consequences there will be no financial compensation for COVID related complications or consequences
• I agree that if I develop COVID-19 I will be treated within the NHS in an appropriate setting

ADDITIONAL POST OPERATIVE INSTRUCTIONS

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COVID-19 post-operative instructions for patients:

In order to protect you and the people who surround you after surgery, we have developed these guidelines for your post-operative recovery. The rules to follow are the same as those during lockdown, but there are some extras specific to your recent surgery. You should follow these instructions for two weeks after your surgery.

Do’s and Don’ts:

Do’s – please try and do the following

Do maintain government guidelines of social isolation even if lockdown is over

If you have had a rhinoplasty, do use nasal saline washouts on a regular basis

If you need to sneeze or cough, then do so into your elbow or into a tissue which you should dispose of immediately

If you start getting symptoms of a viral infection, consider calling 111 or your GP to inform them and socially isolate from others around you

Wear a face mask to protect yourself and others around you

Don’ts – you should avoid the following activities:

Avoid visitors unless they need to make an essential visit

Avoid going out for two weeks unless you need to go on an essential journey

Avoid contact and meeting with anyone who has recently suffered a viral illness

Avoid contact with anyone who has been in contact with large numbers of people

Please do not hesitate to contact MACS TEAM on 0 2070 784 538 or email us on: info@macsclinic.co.uk.

We wish you a pain free, quick and complete recovery.

PATIENT’S PRE-TREATMENT SCREANING COVID-19 QUESTIONNAIRE

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Today’s Date: [TodayShort]

Patient’s Name: [PatientName]

Patient’s Date of Birth: [PatientDoBShort]

You are considering attending the clinic/doctor for a consultation or a procedure. We want you to be well. We are doing everything we can to keep you safe. This questionnaire is designed for the safety of you and the clinic staff. If you or we think that you have a high chance of currently being infected with coronavirus, you should delay your attendance until a safer time, and we may advise this.

Please answer these questions as honestly as you can:

Have you been tested for coronavirus?	Y/N
Have you had a fever in the past two weeks?	Y/N
Have you had a cough in the past two weeks?	Y/N
Have you had any other symptoms suggestive of a viral infection within the last two weeks, such as muscle pain, lethargy, diarrhoea or vomiting, or loss of smell?	Y/N
Have you been exposed to anyone who has had COVID-19 in the past one month?	Y/N
Have you travelled outside the UK in the past 14 days and if so, where did you travel?	Y/N

If you answer YES to any of these questions, we will need to contact you in advance of your attendance.

CLINIC VISIT PROTOCOL

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PREPARING FOR YOUR CLINIC VISIT

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Thank you for booking an appointment with the MACS Clinic. We look forward to welcoming you.  At MACS Clinic we understand that our patients want to get the most out of their consultation, as well as have a safe and comfortable experience here.  Therefore, to help you prepare for your appointment, we would like to advise you that your visit will involve the following: 

• Providing registration information to our administrative team (your full name, date of birth, address, GP details, phone, and email)
• Undergoing a Photo ID Check, so please bring formal photographic identification.
• Completing a Covid-19 pre-screening questionnaire and undergoing a temperature check.
• Undergoing a height and weight check, with a staff member. You will need to remove your shoes.
• Completing a pre-assessment medical history questionnaire, so we can hand details of any significant accidents, surgeries and medical diagnoses, as well as the names and dosages of any medication that you are currently prescribed or taking.
• Completing a psychological questionnaire, so we can hand details of any relevant diagnoses, as well as the names and dosages of any medication that you are currently prescribed or taking.
• Attending a consultation with Mr Vadodaria.  This will involve you discussing your clinical/aesthetic concerns with Mr Vadodaria, and some patients find it helpful to bring a list of concerns/questions to make sure everything is covered.  It will also involve Mr Vadodaria explaining to you his clinical opinion and your potential options for treatments.
• Being examined by Mr Vadodaria in the presence of a chaperone.  Depending on the area of the body you are concerned about, you may need to remove your clothing for the examination.  The chaperone will take you to a separate changing room and you will be provided with a clinic gown for your comfort and dignity. The chaperone will remain with you during the examination.
• Clinical photographs will need to be taken of the relevant area of your face/body, for your medical records.  You will be asked to sign a form to confirm consent to taking the photographs.
• Being given information and advice to assist you in deciding whether to give informed consent to the procedure in due course.  If you want to go ahead with a procedure you may be asked to sign a Consent Form at the time of the consultation, but you can change your mind at any time before the procedure takes place and you will be asked to reconfirm your consent immediately before any procedure is carried out.
• Being asked to provide your feedback about your visit

If you have any comments or concerns about any of these aspects of your forthcoming consultation, please do not hesitate to call us to discuss in advance of your appointment. Please sign and date below to let us know that you have received and understood this information.

CONSENT COVID-19

(For Patients Undertaking Procedure at MACS CLINIC) ________________________________________________________________________________

I have been informed to take an RT-PCR COVID test and then self-isolate for a total period of 72 hours before the day of my operation. I confirm that I have self-isolated and adhere to government guidance of social distancing for the period of 72 hours. Before the date of my operation. I will also self-isolate adhere to the government guidance of self-isolating and will keep social distancing for a period of two week after the date of operation. I understand the COVID-19 related consequences and will be responsible for the same

Signature:           ........................................                           Signature:           ......................................

Date:                     ........................................                           Date:                     ......................................

Patient Name:   [PatientFirstname] [PatientLastname]  Consultant:        …………………………………….