Patient Consent Form

PATIENT CONSENT FORM

    Our priority is the safety of our patients and staff in order to reopen the clinic for face-to-face services. We have had to implement a number of changes which we would like to make you aware of including gaining your consent via this electronic form. It is also our professional responsibility to ensure you are fully informed about the potential risks of infection of COVID-19 and attending a face-to-face consultation.

    Please fill out the required information and read all the information carefully prior to submitting the form and your consent.


    Preference Video ConsultationFace-To-Face Appointment


    Please Indicate If Any Of These COVID-19 High Risk Factors Apply To You:

    Were You Required To Shield During This Pandemic?

    Patients At Higher Risk (Clinically Extremely Vulnerable) - If you fall into the higher risk category you would have most likely received a letter from the NHS.

    Weakened Immune SystemRecent Organ TransplantPregnant With A Heart ConditionSpleen ProblemsAdult With Down's SyndromeHaving DialysisStage 5 (long-term) Kidney DiseaseMedication Affecting The Immune System e.g. High Steroid Dose

    Known Cancer Diagnosis And/Or Currently Having Active Treatment

    Patients At Moderate Risk (Clinically Vulnerable) - If you fall into the moderate risk category you may not have received a letter from the NHS.

    Age >70BMI >40Lung/Respiratory ConditionMedication That Affects The Immune System E.G. Low Steroid Dose

    DiabetesChronic Kidney DiseaseLiver DiseaseHave a Condition That Affects The Brain Or Nerves e.g. Parkinson's, MND, MS or Cerebral PalsyRheumatoid ArthritisHigh Risk Of Getting InfectionsPregnant

    There are other groups of patients that can become seriously ill with Covid-19
    Age >60 (risk increases with age)Black, Asian Or Minority Ethnic Background