Consultation Form

Before you book your consultation please read the following: 

Due to the COVID-19 outbreak we have had to adapt the way we work. 

If you are looking to have any of the following private services provided by Apple Tree Pharmacy, you will be required to fill in the consultation and consent forms prior to the pharmacist assessing your needs. There is a £10 non-refundable fee to be paid for admin and consultation time. 

Once your form has been received by the pharmacist, she will assess the form and call to have a consultation on the phone/face time. She will provide all the information regarding the service you have requested in addition to explaining any potential side effects and address all your questions. If after the consultation an appointment is required for administration of the service, she will book you in for an appointment.  

Please note: 

16 years and over: 

Only the person having the treatment must enter the pharmacy- relatives must wait outside the pharmacy or in the car park. 

Only one person will be seen per appointment. 

Under 16 years 

Only parent to come with the child for the appointment and no other siblings. 

All patients must to have their lower face covered (e.g. a mask or scarf)

The pharmacist will try and minimise the time in the consultation room. As a 2 meter social distancing cannot be adhered to during treatment- she will be wearing full PPE 

(Gloves, mask and apron) during the treatment. 

You will be asked to use hand gel upon entering the consultation room and a your temperature will be taken using a non touch thermometer. 

NO FOOD or DRINK is allowed to be consumed on premises or in the consultation room. 

Time must be minimal during the appointment so please ensure you have asked all the questions prior to appointment. 

 

Please read this statement carefully as you will be consenting to treatment.

I understand that I am opting for an elective treatment of vaccination

I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization 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 (see website for details) 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 (see website for full details). 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 hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment, and I give my express 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, in addition to those risks associated with the treatment.

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.

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

Your Name (required)

Your Email (required)

Your Contact Telephone Number (required)

Consultation of interest
TravelChicken poxHay FeverWeight LossAesthetics

Brief Summary Of Consultation You Require:

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