WOW Fusion Consent Information with Additional Patient Consent for Treatment During COVID-19 Pandemic
I understand that I am opting for an elective medical consultation/treatment/procedure.
I understand that the novel coronavirus, 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, 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 treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective consultation/medical treatment/procedure, 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/procedure itself.
I have been given the option to defer my medical consultation/treatment/procedure 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 treatment/procedure I confirm that I am not presenting with any of the following symptoms of COVOID-19 listed below:
• Shortness of Breath
• Loss of Sense of Taste or Smell
• Dry Cough
• Runny Nose
• Sore Throat
I understand that air travel significantly increases my risk of contracting and transmitting the COVID19 virus. I confirm that I have not travelled in the past 15 days.
I confirm that if I develop COVID-19 symptoms following my medical
consultation/treatment/procedure 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 I confirm I have been informed that.
I understand that further lockdown may impact on managing complications and immunological reactions.
WOW fusion® INFORMED CONSENT FORM
The WOW fusion® device is a small needling device with a glass vial attached that allows your practitioner to make a skincare serum that is suitable for your skin condition.
The needle head contains 20 titanium gold plated needles that are 0.13mm in diameter. These needles are then pushed in to the skin in a gentle stamping motion and the bespoke skin care ingredients are delivered into the skin below the surface to work at a cellular level. The results from the WOW fusion® treatment will vary depending on what ingredients have been selected for you by your practitioner. It is possible that during and after your WOW fusion® treatment you may experience the following side effects:
• Slight discomfort or pain
• Redness and erythema
• Slight bruising
• Pin prick bleeding
The following issues are not recommended for WOW fusion® treatment, please tick if you suffer with any of the following and your practitioner will discuss this further with you:
• Active acne
• Haemophilia / bleeding disorders
• Active infection of any type such as coldsores (bacterial, viral, or fungal)
• Skin Cancer
• Blood thinning medications
• Keloid/hypertrophic scarring
• Uncontrolled diabetes
• Eczema, Psoriasis, or Dermatitis
I consent to my practitioner using a solution that may comprise of:
• Botulinum toxin type A
• WOW fusion® Serum
• Hyaluronic Acid
• Multivitamin Complex
• Anti-ageing Complex
• Whitening Complex
• Hair Complex
• Any suitable solution that the practitioner may advise
Avoid sun exposure and always wear a minimum of SPF 30. No saunas or steam rooms for 2 weeks post treatment. Moderate exercise allowed on the day of treatments. Avoid make-up for 12 hours if you can. Keep skin moisturised and never pick or peel your skin if it feels rough or is flaking.
I understand that there are risks involved with micro needling and I can discuss any concerns I have with the practitioner. I have asked all the questions I have about the WOW fusion® and understand potential risks and complications. I agree to follow all post care advice given to me by the practitioner.
I have answered all questions to the best of my knowledge and I am happy for the practitioner to commence with the WOW fusion®.