COVID-19 Client consent form

Please fill in the following form prior to booking for any treatment.

Medical Aesthetics Hereford

COVID-19 Client Consent Form

I understand that I am opting for an elective aesthetic procedure/consultation.

I understand that the novel corona virus, 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 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 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 the treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective aesthetic procedure/consultation 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 aesthetic procedure/consultation itself.

I have been given the option to defer my aesthetic procedure/consultation 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 aesthetic procedure/consultation.

I confirm that I am not presenting with any of the following symptoms of COVID-19 listed below:
Shortness of Breath
Loss of sense of taste or smell
Dry cough
Runny nose
Sore throat

I confirm that I have not been in contact with a confirmed COVID-19 person or persons with the above symptoms in the past 14 days.

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 aesthetic procedure/consultation, or a known contact of mine develops symptoms, I will immediately inform the clinic to enable appropriate measures to be put in place and contact tracing to commence.


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