COVID19

Pre-treatment Questionnaire This pre-treatment questionnaire is currently in place due

to the emergence of covid19 and the global pandemic. (2020)

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Please complete fully and as honestly as you are able. It is required that this is completed

as a minimum 72 hours prior to your appointment time.

Please complete this form by entering the required information into the GREY SHADED

ENTRY AREAS WHERE appropriate and return to FACE2FACE MEDICAL AESTHETICS Karen

Svolkinas, the nurse practitioner, no later than 48 hours before your appointment where

the information will be assessed to see whether your treatment can be undertaken.

You will be asked to complete this form twice, once by email and once when you attend

the clinic for your appointment.

Failure to do this will mean that your appointment will be cancelled, and your booking

deposit is non-refundable. No refunds are given if you fail to comply with the above or fail

to attend your appointment.

This completed form must be returned to: face2face1359@gmail.com

DETAILS:

NAME:

ADDRESS:

DOB:

TEL:

EMAIL:

What treatment have you booked:

Date of appointment:

FIRST form: completed DATE: YES NO

SECOND form:

• to be completed on

attendance to the clinic.

DATE: YES NO

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PLEASE ANSWER ALL OF THE QUESTIONS

1. Have you had close contact with or cared for someone

diagnosed with Covid19 within the last 14 days?

YES NO

2. Have you been tested positive, suspected of having or

been treated for covid19 in the past 28 days?

YES NO

Have you had any of the following:

• a throat or nasal swab taken? YES NO

• Did you test positive or negative? YES NO

• What was the date of the test? DATE:

Have you had an antibody test?

• Was the test positive or negative? YES NO

• What was the date of the test? DATE:

3. Have you been in close contact with anyone who has

travelled abroad, within the UK , been on a cruise

ship or attendee an event in the last 15 days?

YES NO

4. Have you attended any events or gatherings

with more than 100 people?

YES NO

5. Have you or anyone you have been in contact

with been asked to self-quarantine?

YES NO

6. Are you pregnant or breast feeding? YES NO

7. Are you over 70 years of age? YES NO

8. Do you suffer from any of the following?

• Diabetes YES NO

• Cardiovascular disease

Including hypertension, chronic lung disease,

immunodeficiency?

YES NO

• Cancer (undertaking active treatment) YES NO

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9. Do you have any cold/flu like symptoms including the following?

• Cough YES NO

• Sneezing YES NO

• Fever YES NO

• Fatigue YES NO

• Shortness of breath YES NO

• Loss of smell YES NO

• Temperature – YES NO

37.8 degrees or over.

• Loss of taste YES NO

• Diarrhoea YES NO

• Vomiting YES NO

• Unusual rash YES NO

• Redness of the eyes YES NO

• Muscle weakness YES NO

• Muscle pain YES NO

FAMILY AND CLOSE CONTACTS;

Are any of your family members or immediate/close contacts currently sick or

experiencing:

1. Fever, cough, shortness of breath or flu like symptoms? YES NO

2. Sore throat, muscle aches, fatigue, nausea & diarrhoea? YES NO

3. have any of your family members or immediate close

contacts been diagnosed with Covid19? YES NO

• If YES, when? DATE:

PLEASE NOTE:

DERMAL FILLER TREATMENT

• There is increasing evidence that dermal fillers given in the presence of resent viral

infection (or where the virus is caught after treatment) can INCREASE THE RISK OF

DELAYED HYPERSENSITIVITY REACTIONS.

As the patient I fully understand and consent to dermal filler treatment.

• Present evidence has demonstrated that by rinsing the mouth with 1.5% hydrogen

peroxide, 0.2% povidone-iodine, Corsodyl(chlorhexidine) or Colgate Poroxyl mouth

wash 1.5% for 1 minute immediately before the procedure or before you attend

your appointment is necessary, to reduce the risk of contamination.

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This can help to minimise the risk of infection, specifically prior to lip injections, and

treatment around the lower face with soft tissue dermal fillers. Any patient who is

to have lip filler or filler to the lower third of the face, will be asked to obtain any of

the above mouth washes and instructed to use this prior to treatment being

performed. You will also be advised to brush your teeth using Corsodyl toothpaste.

WE DO NOT FACILITIES FOR MOUTHWASH OR TEETH CLEANING AT THE CLINIC.

Ref: Journal of dermatologic therapy – Covid19 pandemic: Consensus guidelines for preferred

practices in an aesthetic clinic (May 2020)

FACE MASKS

I understand that:

• I will be asked to wear my own protective face mask upon attendance to the clinic.We

have a limited supply of masks at the clinic, these can be purchased for aminimum

donation of £1, proceeds for these sales will be donated to charity.

• Additional infection control measures have been implemented by face2face cosmetic

aesthetics and will comply with any requests to don the necessary PPE before, duringand

following any procedure performed by Karen Svolkinas, nurse practitioner atface2face

cosmetic aesthetics. I accept that infection control measures CANNOTcompletely remove

all risks in relation to Covid19.

GDPR Compliance (General data protection regulation)

I understand that:

• my personal information/clinical notes are stored securely and not shared with a third

party unless I have given my consent.

• the nurse prescriber at FACE2FACE MEDICAL AESTHETICS will order a prescription for the

products that are required to perform my treatment on my behalf.

• I therefore allow my, name, address, date of birth and any relevant medical/treatment

information to be shared with my GP if appropriate, relevant medical and thepharmacyselected by the

nurse prescriber at FACE2FACE MEDICAL AESTHETICS.

Karen Svolkinas - nurse practitioner

FACE2FACE MEDICAL AESTHETICS

SIGNED DATE:

PRACTITIONER: DATE:

click on the email address to return your completed form to:

face2face1359@gmail.com alternatively save to your machine and email