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Pre-Appointment Form

*Important information regarding your treatment and the COVID-19 vaccine*

There is new advice to not have a dermal filler treatment for 2 weeks before the vaccine or 3 weeks after the vaccine.

No toxin treatment 1 week before the vaccine and 2 weeks after the vaccine.

If your appointment falls in these time frames please contact me as soon as possible and I'll rearrange your appointment as best I can.

Please complete the form below to progress to your appointment with Nova Skin & Laser Clinic

All questions are essential to provide you with a safe and thorough appointment experience.

All information is held securely and confidentially.

*Should the form not submit please scroll to the top of the form and any error/correction needed will be highlighted*

Patient Information

Emergency Contact
COVID-19 Screening
Have you had COVID-19? (proven by positive test)?
Have you been in contact with or are living with someone suspected or confirmed of having COVID-19?
Do you have a fever, or have you had a high temperature in the last 14 days (a fever is a temperature greater than 37.8C?
Have you had a loss of or change in your normal sense of smell?
Have you had a cough or any other respiratory signs in the last 14 days?
Do you suffer from any of the following? If yes, please select which, otherwise select no.
Diabetes
High blood pressure
Heart disease
Chronic lung disease (asthma, COPD)
Immune system deficiency
Active cancer and having treatment
Are you pregnant?
Are you over 70 years of age?
Have you had your FIRST COVID-19 vaccine?
Have you had your SECOND COVID-19 vaccine?
COVID-19 Consent

We shall continue with our usual Consent Process and complete the individual treatment Consent forms per treatment. In addition to this a COVID-19 Consent form must be completed when every patient is having a treatment.
I understand that I am opting for an elective treatment that may not be essential but that I feel is necessary for my well-being.
I also understand that the novel coronavirus, SARS-CoV2 which has caused COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that SARS-CoV-2 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, the UK Government and healthcare agencies recommend social distancing with the exception of necessary activities.
I recognise that reasonable preventative measures aimed to reduce the spread of COVID-19 have been put in place .
However, given the nature of the virus, I understand that there is an inherent risk of becoming infected with SARS-CoV2 by meeting with people in any environment or visiting areas with high traffic volumes. The wearing of appropriate Personal Protective Equipment (PPE) has been shown to be effective at reducing this risk (but not eliminating it) in medical environments.
I understand that I increase the risk of getting COVID-19 by leaving my house for any reason including attending my appointment at Nova Skin & Laser Clinic. If I become infected, I risk passing this on to those people I meet and live with including those who are shielding. I understand and will adhere to the Clinic’s infection control policy as advised.
Minimally invasive Cosmetic Treatments are low risk Medical Procedures with respect to SARS-CoV2 transmission but are not risk free. I understand, acknowledge, and assume responsibilities for these risks.
I understand that, even if I have been tested for COVID-19 and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID-19 after the test.
I understand that I may not show any symptoms even after being infected with SARS-CoV2.
I understand that possible exposure to SARS-CoV2 before/during/after my treatment may result in the following: a positive COVID-19 diagnosis, extended self-isolation, additional tests, hospitalisation that may require medical therapy.
I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described, as well as those risks for the treatment itself.
I am aware of 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.
It is possible that I may become positive for COVID-19 before, during or after my treatment. It is also possible there will be a second wave of infections that require a further lockdown and the closing of the clinic. This may affect my follow up treatments, planned course of treatments or review appointments. Should that happen, we will be unable to see you in person and any assessment, management and support can only be provided by telephone or video call, remotely. Corrective treatments will be delayed until lockdown is released. If this risk is unacceptable you should not proceed with any treatment. No refunds or financial compensation can be offered for circumstances beyond our control. By booking a treatment you are accepting these risks and terms.
I UNDERSTAND THE EXPLANATION AND HAVE NO MORE QUESTIONS AND CONSENT TO THE PROCEDURE.

I am the patient
Aesthetic Interest Questionnaire

What is the main reason for your visit today? What would you like to achieve?

How often do you think about wanting a cosmetic procedure?

Which three statements best reflect how you would like to look and feel after the treatment?

How would you rate the quality of your skin?

If you could enhance an aspect of your skin, what would you enhance?

These skin enhancement treatments interest me:

MEDICAL HYSTORY
Have you previously had any cosmetic procedures (surgical or non-surgical)? If yes, please give details
Have you previously been admitted to hospital? If yes, please give details? (medical or surgical admissions).
Are you taking any medication? (prescribed by your doctor or over the counter including vitamins/supplements)?
Are you currently under a specialist or receiving treatment from a doctor? If yes, please give details.
Have you been diagnosed with any medical conditions regardless of whether they are controlled or not and you are NOT taking medicine for it? If yes, please give details.
Do you have any other allergies? If yes, please give details.
Have you ever had a severe allergic reaction or anaphylaxis? If yes, please give details.
Do you smoke?
Do you drink alcohol?
Do you take regular exercise?

Medical Conditions - have you suffered from any of the following? If yes, please give details in the box below.

Are you pregnant or breast-feeding?
Do you have any current skin infection or inflamed skin in areas to be treated?
Do you suffer from porphyria? (a skin and nervous system disease)
Are you allergic to local or topical anaesthetics? (numbing cream)
Have you taken Roaccutane (for acne) in the past 12 months?
Are you using Vitamin A/retinol/tretinoin in your skincare regime?
Are you taking aspirin/warfarin or other blood-thinning medication?
Are you taking or receiving steroids, chemotherapy or radiotherapy?
Do you suffer from keloid (thickened, overgrown) scars?
Do you consent to use of a local anaesthetic (numbing) cream if needed?
Do you feel your treatment is essential to maintain your own mental health and well-being?
Terms & Conditions of Appointments & Treatments
Appointments & Cancellations
I agree for Nova Skin & Laser Clinic to contact me with occasional information about other services we provide, or may provide, in the future.
I give consent for my email address to be added to Nova Skin & Laser Clinic mailing list
Treatment Suitability

We will always assess whether treatment is suitable for you, or likely to be successful, prior to any treatment being carried out. If not, we will inform you as to the reasons why. You will be liable for the cost of the initial consultation, where applicable.

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Courses of Treatments

All treatments purchased us a course must be paid for in full in advance of the first treatment.

If you are unable to attend your appointment, we require 24 hours' notice. Failure to give notice will result in you losing a treatment of your course of treatments.

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Medical Conditions

Please let us know if you have any medical conditions, as some conditions may prevent you from having certain treatments. Let us know of any medication you are taking. If you are prescribed medication during a course of treatment, please let us know. All information will be kept strictly confidential. Pregnancy, even if no one else knows, please inform us if you are pregnant, or think for any reason you may be pregnant prior to treatment.

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Permission of Photos

Each patient agrees that Nova Skin & Laser Clinic Doctor or therapist may take photos for the purpose of their general identification within the clinic.

Photos of the concerned areas of yourself may be taken before the start of the first treatment, and in midst of the course. This is for your benefit, to show you the differences in the skin complaint/initial concern you had, or initially came to us with.

Treatment photos will only be used for Nova Skin & Laser Clinic marketing (leaflets, website, social media pages etc.) with a patient's permission. Elevate Medical Aesthetics does not offer any reward or financial benefits for the use of these images.

I give consent for 'before and after' photographs to be taken of me and used sensitively by Nova Skin & Laser Clinic for marketing
Liability

Nova Skin & Laser Clinic requires that you read and understand all relevant consent forms and sign a form for each treatment that you come in for. This is to tell you about the treatment, it's possible side effects and aftercare you agree to follow.

You will be asked to complete a health questionnaire, which will be asked at every treatment in the course, so let Nova Skin & Laser Clinic doctor, nurse, therapist know it anything has changed with regard to your health or medications. Once you have signed the consent, it means you are responsible for any change that we were not aware of E.g. Sun tan on a holiday which was recent, but not mentioned - the use of tinted moisturiser etc.).

We will not be liable nor bound by contract or otherwise for any economic loss (including, without limitation, loss of profit), or for any other special, indirect or consequential loss or damage arising from, or in connection with, provision of any goods and / or services for the client by Nova Skin & Laser Clinic.

The patient agrees to comply with all instructions and / or recommendations given to them by, or on behalf of Nova Skin & Laser Clinic doctor or other team member regarding the care of the area treated.

Payment Terms

We accept cash and the following credit cards: Visa, MasterCard, American Express, Debit Cards, Maestro (formerly Switch) and Solo. We do not accept cheques. Payment must be made either in advance, or at the time of the procedure.

All treatment bookings must be for in full, on arrival at the clinic, prior to treatment commencing.

 
Refund Policy

At Nova Skin & Laser Clinic doctor all of our products are sold as brand new and are for personal use only. We cannot give refunds on any products sold due to personal hygiene and health and safety reasons.

All of the treatments by Nova Skin & Laser Clinic are completed by qualified Practitioners Therapists and Doctors. If you have had treatment that you are dissatisfied with please contact us immediately.

Due to the medical nature of our services, involving prescription medications we cannot give refunds on any treatments but we will look into your concerns immediately.

 
Your Right to Complain

We are committed to providing a professional service to all our clients. We do however, have a complaints procedure in place and if for some reason you are unhappy with your treatment, and feel you want to make a complaint, or comment on the service provided, you are entitled to do so in writing.

The complaint should be made in writing, the complaint will be recorded and dealt with in the appropriate manor, and you will receive a response within 28 days. Please contact Elevate Medical Aesthetics for further details, or email hello@novaskinandlaser.co.uk. We will endeavour to deal with matters arising promptly and efficiently. If you are not satisfied with our initial attempt to resolve any issues highlighted, then the Company Executive will review your case. You agree to waive your right to trial in civil court or by judge or jury and agree that disputes will be settled by mandatory arbitration of which shall be selected by Nova Skin & Laser Clinic.

Final Declaration

By my signature below, I certify that the information provided above is true, accurate, and complete at the date provided on this form. If any aspects change then I agree to inform Nova Skin & Laser Clinic.

Thanks for registering

Initial consultations are free of charge. However, we may take a £30 deposit to secure the appointment time. If you decide to purchase treatments or products then the £30 will be taken off the total amount payable, or alternatively. If you do not decide to go ahead with treatments, the deposit will be refunded in full.

If you fail to provide us with 24 hours’ notice for cancellation, the deposit is non-refundable.

Being on time for your appointment is greatly appreciated. Likewise Nova Skin & Laser Clinic team will try to run on time to the best of our ability. In the event that you are late for an appointment, it is important that you contact the clinic so we can try and alter your appointment accordingly. We will be happy to provide the remaining portion of the allocated treatment time when next appropriate.

Very occasionally, due to unforeseen circumstances, we may need to cancel your appointment at short notice. In this unlikely event, we will make every attempt to contact you to inform you and to rearrange your appointment to a mutually convenient time. Nova Skin & Laser Clinic does not offer compensation if we cancel your appointment.

All doctors/nurses/therapists are trained and approved in accordance with the Nova Skin & Laser Clinic treatment protocols, and therefore, we cannot guarantee continued treatment with a named doctor or therapist.

Prior to your appointment, we will inform you of any preparation required in advance of your treatment. Failure to follow the guidelines may result in cancellation of your appointment, reduced treatment time, or additional fees being charged.

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Courtesy

I accept that the clinic is a non-smoking building.

Nova Skin & Laser Clinic cannot allow children under 18 to come into the clinic unless accompanied by a responsible adult. If this adult is receiving a consultation or treatment, an additional adult must accompany the child, as we cannot allow anybody who is not receiving or contributing to the clients care into the treatment room.

Nova Skin & Laser Clinic has a strict no photography policy. Due to the image quality of both cameras and phone / tablet cameras becoming increasingly higher, it is a confidentiality hazard, as sensitive materials could be photographed, or the identity of another clinic client could be revealed, without their consent. For these reasons, anyone found to be taking photographic or video footage will be asked to leave the clinic immediately and will have any future treatments refunded in the form of a credit note, which will only be redeemable against the purchase of our own brand products.

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Personal Details

You agree that Nova Skin & Laser Clinic can use your personal details for the purposes of providing you with medical and non-surgical services, as well as providing pre- and post-treatment post-treatment advice for you.

This information may be provided to other clinical organisations and individuals including but not limited to Executive Directors, Nurse Prescribers, Dentists, or other Aesthetic Practitioners working for the clinic) for the same purposes.

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