Cryopen Treatment consent form

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

Yes

Personal Details

Name (required)

Date of Birth (required)

Contact Number Mobile

Emergency Telephone Number

Email (required)

GP surgery name (required)

Medical Details

What are your primary skin concerns that you wish to be treated with Cryopen?

How many lesions do you wish to have treated?

Please send good quality pictures. Do not upload any patient identifiable photos. The photos should be only of the lesion and should be a clear image.

Consent
Yes

This disclosure is simply an effort to better inform you so that you may give consent to treatment.
By ticking the consent box you are requesting a consultation (followed by possible treatment if suitable) for Cryopen Therapy for the removal of your benign skin lesion (Skin tag, skin wart, brown spots, skin verruca, cherry angioma). By consenting you are confirming that the skin lesion is benign and if you had any concerns otherwise you have cleared and had approval by a medical practitioner prior to this treatment. I understand that the pharmacist will call me to explain the procedure along with the potential risk and benefit from the treatment, I will take this opportunity to discuss the treatment and ask all my questions. I understand that the pharmacist may decide that this treatment may not be suitable after the consultation.

By clicking this box I agree to the terms outlined above and I understand and consent to the administration of the advised medicine and allow the pharmacist to use the information I have supplied to keep as medical records (in line with GPDR). I also agree to pay a £10 consultation fee. If a treatment is administered after the consultation, this fee is deducted from the cost of the treatment. If no appointment is booked after assessment of the consultation form, this fee is non-refundable.

This form is an advanced consent to treatment – to minimise time spent in the pharmacy as we cannot maintain a 2 meters distance safely for the duration of your visit. However, we will perform a consultation where you will have the opportunity to ask questions and the pharmacist will cover all the potential risk of treatment.

Information provided by:
I have provided this information about myselfI have provided this information on behalf or someone else
Please provide your full name if providing this information for someone else:

Input this code: captcha