INFORMED CONSENT ABOUT COVID-19 RISK
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.
ADDITIONAL POST OPERATIVE INSTRUCTIONS
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: email@example.com.
We wish you a pain free, quick and complete recovery.
PATIENT’S PRE-TREATMENT SCREANING COVID-19 QUESTIONNAIRE
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?
|Have you had a fever in the past two weeks?
|Have you had a cough in the past two weeks?
|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?
|Have you been exposed to anyone who has had COVID-19 in the past one month?
|Have you travelled outside the UK in the past 14 days and if so, where did you travel?
If you answer YES to any of these questions, we will need to contact you in advance of your attendance.
CLINIC VISIT PROTOCOL
PREPARING FOR YOUR CLINIC VISIT
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:
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.
(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: …………………………………….