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.
- I understand, from my surgeon and clinic, that I am undergoing an elective surgical procedure through my own choice.
- I understand that COVID-19 is an infectious disease that has been declared a worldwide pandemic by the World Health Organisation and is associated with death in some people.
- I understand there is a risk that I can catch COVID-19 before, during or after the time of surgery
- If I suffer from COVID-19 I accept that it can be impossible to determine the contagious source of the disease
- I understand that even if I have been tested for Coronavirus and received a negative test, the results in some cases fail to detect the virus. I also accept I can contract COVID-19 after a test has been performed.
- I understand that if I suffer from COVID-19 after surgery, there might be a higher risk of death and suffering from the disease
- I understand that contracting COVID-19 may result in the following; extended quarantine/self-isolation, additional tests, hospitalisation that may require medical therapy, intensive care therapy, intubation/ventilator support, increased complications for the treatment I am having, and other potential complications associated with COVID-19 treatment.
- I understand that COVID-19 is a new disease and there may be additional risks that are currently unknown and that it is not possible to quantify the risk of complications right now.
- I have been given the option to defer my treatment to a later date, I have been given the option to cancel my treatment and I would like to proceed with my desired treatment in full knowledge of the risks in this consent form.
- I agree that if I develop symptoms, have contact with anyone or have been tested for coronavirus then I will inform my surgeon.
- I agree that if I develop COVID-19 and suffer consequences there will be no financial compensation for COVID related complications or consequences
- I agree that if I develop COVID-19 I will be treated within the NHS in an appropriate setting
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: firstname.lastname@example.org.
We wish you a pain free, quick and complete recovery.