Patient consent for consultation or treatment during COVID-19 pandemic
14th January 2021
COVID-19 national lockdown
The government has published rules and restrictions relating to COVID-19 which stress the importance of staying at home during this crisis. This guidance can be accessed here. The rules state that medical services can remain open and that travel for medical appointments is permitted.
The Maitland Clinic carries out medical services and specialises in the diagnosis and treatment of hair loss and its associated psychological symptoms. We recognise the psychological impact caused by hair loss, including anxiety and reduced self-esteem and self-confidence.
You may feel that it is appropriate to delay your hair restoration consultation or treatment until the COVID-19 national lockdown has been lifted. We would fully support you in this decision and would be pleased to explore alternative dates later in the year. However, we appreciate the significant medical benefits that can be gained from hair restoration, in terms of reduced anxiety and improved self-esteem and self-confidence. We are also aware of the major psychological and logistical steps that have been undertaken in order to secure a date for your appointment.
Therefore, if you feel that your medical appointment is essential at this time, we would be pleased to see you planned and will do all that we can to support you in making your travel and your time at The Maitland Clinic as safe and COVID-secure as possible.
A summary of our COVID-19 policy can be accessed here. If you would like more information about how we are operating as a COVID-secure clinic please get in touch via firstname.lastname@example.org.
Do you feel that it is essential that you proceed with your medical hair restoration consultation during the COVID-19 lockdown?
Yes / No
If you feel that it is essential for you to undergo your medical hair restoration consultation at this time, please provide your reasons.
- Psychological reasons (for example, anxiety relating to hair loss, reduced self-esteem, reduced self-confidence)
Please provide details:
Consent to attend The Maitland Clinic for consultation or treatment
I understand that I am opting to attend The Maitland Clinic for a medical consultation or treatment. 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 consultation or 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 Maitland Clinic 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 my consultation or treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through attending this medical appointment, and I give my 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.
I have been given the option to defer my hair restoration consultation or 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 appointment at The Maitland Clinic.
I confirm that if I develop COVID-19 symptoms following this consultation or treatment, or a known contact of mine develops symptoms, I will immediately inform The Maitland Clinic to enable appropriate measures to be put in place and contact tracing to commence.