Clinic Forms

Please go through the "Contact" page if you you like to arrange an appointment or ask a question. The Contact Form is shorter and is all that is needed for the first contact.

This page has 4 Forms. You will be asked to complete the relevant Forms once you have booked an appointment. Everyone will need to fill out Forms 1 and 2. The Registration Form (Form 1) includes all the details needed prior to a consultation. There is also a Consent Form for an on-line virtual consultation during the COVID-19 pandemic (Form 2). As part of the booking process you will receive electronic versions of the Forms which tell you why we need to collect this information from you, and what is done with the information.

People attending for a treatment will also need to fill out Forms 3 and 4. The Screening Checklist (Form 3) should be completed prior to your attendance. Finally, there is a Consent Form for Treatment during the COVID-19 pandemic (Form 4) which highlights the risk of transmission of COVID-19 during close contact.

Before submitting your Forms, click here to read our Privacy Notice to find out what we do with your information. 

 

lichfield face Clinic

Dr. Anne Ward

Consultant Dermatologist

Form 1: Registration Form

Form 2: Consent Form for an On-Line Consultation 

Please print off this section, and keep a copy of the "Consent Form for an on-line Consultation" for your own records:

 

An on-line remote or virtual consultation, along with good quality photographs, is a good method of diagnosing and managing certain skin rashes, such as acne or rosacea. It is also used to assess people prior to having a cosmetic procedure performed, or before minor skin surgery, as it helps to reduce the contact time in clinic, thereby reducing the risk of transmission of Covid-19. 

 

There are some limitations to using an on-line virtual consultation. The main problem is that sometimes the image resolution of the video is a bit blurry. This is why you are asked to send in several good quality photographs before your consultation as this helps in making an accurate diagnosis. However, even with photographs, an on-line consultation may not always distinguish a benign skin lesion from a possible skin cancer. 

   

Please click on the options below to confirm that you are aware that an on-line virtual consultation may have possible limitations compared to a face-to-face consultation. By submitting this Form, you are consenting to an on-line consultation. 

Form 3: Screening Checklist for Covid-19

Please tick the Boxes below to confirm that you have read each question. 

If the answer is "YES" to any of the questions - please give more details in the Comment Box.

If all the answers are "NO" - please write "NO" in the Comment Box.

Form 4: Consent for Treatment During Covid-19

Please print off this section, and keep a copy of the "Consent for Treatment during COVID-19" for your own records:

I understand that I am opting for an elective medical consultation / treatment. I understand that the World Health Organization has declared COVID-19 a worldwide pandemic and that COVID-19 is extremely contagious and is believed to spread by person-to-person contact and is potentially fatal. As a result, social distancing is recommended, but this is not possible with my proposed treatment. I am satisfied that safety measures are in place to minimize risk as much as possible, and patient contact will be kept to an absolute minimum in line with medical need.

 

I understand that Dr Anne Ward is closely monitoring the COVID-19 situation and has 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 treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective medical consultation / 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 medical consultation / treatment itself. 

 

I have been given the option to defer my medical consultation / 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 medical consultation / treatment. 

 

I confirm that I am not presenting with any of the following symptoms of COVID-19: Temperature or feeling feverish; New Cough or Dry Cough; Sore throat; Shortness of breath; Runny Nose; Flu-like symptoms such as fatigue, headache; Nausea or Diarrhoea; Chills or shivering; Muscle pains or rash; Loss of Sense of Taste OR Smell. 

 

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. I confirm that I have not travelled in the past 14 days 

 

I confirm that if I develop COVID-19 symptoms following my medical consultation / treatment or a known contact of mine develops symptoms, I will immediately inform the practitioner to enable appropriate measures to be put in place and contact tracing to commence. 

By confirming your name, address and DOB in the sections below - you are acknowledging that you have read, understood the risks of COVID-19 transmission with close contact, and agree to having treatment during the COVID-19 pandemic. Please write in the Comment Box stating that you agree to treatment.

Lichfield Face Clinic

Dr Anne Ward

Consultant Dermatologist

Borrowcop Lane

Lichfield WS14 9DG