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COVID-19 Appointment Consent

Triage & Consent for Treatment During COVID-19 Pandemic

Please note that you will need your FACEmed unique reference number in order to complete this form, this was given to you over the phone when booking your appointment, this can also be found on your appointment confirmation email.
Your Appointment Date*
DD slash MM slash YYYY
Name*
First Last
I understand that I am opting for an elective medical treatment/procedure/surgery.*
- Yes
- No
Are you currently suspected of having COVID-19?*
- Yes
- No
Have you been in contact with or are living with someone suspected of confirmed of having COVID-19?*
- Yes
- No
Do you have a fever or have you had a fever/high temperature in the last 10 days (greater than 37.8)?*
- Yes
- No
Have you had a cough or any other respiratory signs in the last 10 days?*
- Yes
- No
Have you lost your sense of taste or smell?*
- Yes
- No
Do you suffer from any system diseases that cause immunodeficiency or have you been advised to shield? (Eg. Diabetes, liver disease, cardiovascular disease including hypertension, chronic lung disease, immunodeficiency, cancer under active treatment?)*
- Yes
- No
Are you over 70 years of age?*
- Yes
- No
I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization 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.*
- Yes
- No
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 medical treatment/procedure/surgery, and I give my express permission to proceed.*
- Yes
- No
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 treatment/procedure/surgery itself.*
- Yes
- No
I confirm that I am not presenting with any of the following symptoms of COVID-19 • Fever • Shortness of Breath • Loss of Sense of Taste or Smell • Dry Cough • Runny Nose • Sore Throat*
- Yes
- No
I confirm that if I experience any of the following symptoms of COVID-19 listed below at any stage between now and my appointment time then I will not attend the Centre, I will advise FACEmed by phone; Fever • Shortness of Breath • Loss of Sense of Taste or Smell • Dry Cough • Runny Nose • Sore Throat*
- Yes
- No
I confirm that if I develop COVID-19 symptoms following my medical treatment/procedure/surgery, or a known contact of mine develops symptoms, I will immediately inform FACEmed to enable appropriate measures to be put in place and contact tracing to commence.*
- Yes
- No
I understand that this form will suffice for all future appointments during the COVID-19 pandemic and that should any of my information change or should I develop any symptoms or become ill I will notify FACEmed by phone before attending the Centre.*
- Yes
- No

Telephone:

01268 833680

Email:

enquiries@nullfacemed.co.uk

Address:

FACEmed Cosmetic Medical & Dental Centre
Crays Hill
Billericay
Essex
CM11 2XP

Call 01268 833 680

AREAS OF EXPERTISE

Dentistry
Surgical Procedures
Cosmetic & Medical Injectables
Aesthetic Treatments and Skincare

INSTAGRAM

Non-Surgical Browlift! Looking for a subtle enhan

Non-Surgical Browlift!
Looking for a subtle enhancement with the greatest impact? The non-surgical browlift with muscle relaxants is an innovative procedure offering a natural looking lift to your eyebrows, leaving you with a refreshed and youthful appearance.
By strategically injecting muscle relaxants, we target specific muscles to gently lift your brows, reducing sagging and wrinkles. The result? A rejuvenated look without the need for surgery!
Benefits you'll love:
Natural looking results
Minimal downtime
Quick and convenient
Versatility tailored to your needs

Book your complimentary initial assessment on 01268833680 or email hello@facemed.co.uk
#facesbymon #FACEmed #musclerelaxants #aesthetics #Billericay #Brentwood #Essex #Browlift #nonsurgicalbrowlift #injectables #Youthfullglow

The Magic at FACEmed really happens when our multi

The Magic at FACEmed really happens when our multidisciplinary teams work together to give patients the best outcome possible. Thank you to our lovely patient for allowing us to show the results of her upper eyelid surgery combined with ongoing muscle relaxant injections. A true success story from the Surgical and Medical Aesthetic teams working together.
Book your complimentary initial assessment on 01268833680 or email hello@facemed.co.uk
.
#aesthetics #surgery #facemed #essex #eyelidsurgery #aestheticinjectables #wrinklereduction #billericay #medicalonly #browlift #facelift #blepharoplasty

FRESH FRIDAY FEELING 💫🦷🪄🪥 come watch o

FRESH FRIDAY FEELING 💫🦷🪄🪥 come watch our Hygienist @smiles_by_alysha in action!

Save yourself from future dental problems by seeing a Dental Hygienist regularly.

Have you had professional Hygiene therapy in the last six months?

Against a calming backdrop the experts work their

Against a calming backdrop the experts work their magic 🤍
Sitting quietly on the outskirts of Billericay Essex the talented team at FACEmed are restoring confidence and enhancing lives 🪄
.
.
#essexsurgery #essexdentistry #facemed #walkwithme #daysurgery #noflowerwalls

💜We’re proud to offer BlancOne®🦷, a revol

💜We’re proud to offer BlancOne®🦷, a revolutionary in-clinic teeth whitening system that can brighten your smile by up to 5 shades in just one session😍. BlancOne® is a safe and effective treatment that is perfect for patients who want to achieve a whiter smile without the hassle of at-home whitening kits.⭐
.
BlancONE in-surgery teeth whitening is ideal for an up coming event due to its instant results. 🤍🌟
☑️Fast results: See a brighter smile in as little as 10 minutes.
☑️Safe and effective: clinically proven treatment that is gentle on your teeth and gums.
☑️No sensitivity: formulated to minimise tooth sensitivity.
☑️Convenient: done in the comfort of the dental chair.

We offer a complimentary 20min smile assessment. Call us for more information on 01268 833680 or DM.

#facemed #blanconewhitening #brentwood #billericay #teethwhiting #instantresult #ConfidentSmile #SafeAndEffective #SmileTransformation #airflowdentaltreatment #brightsmile #gentledentalcare #dentalhygiene #stainremoval #oralhealth #teethcleaning #dentistessex #hygienistessex

🫦💉Revitalise your Lips with Injectable Lip H

🫦💉Revitalise your Lips with Injectable Lip Hydration Treatment😍💋
This non-invasive treatment offers a subtle yet effective way to achieve plump, hydrated lips.
Injectable lip hydration involves the use of hyaluronic acid based dermal fillers to enhance the volume and moisture levels in the lips. Hyaluronic acid is a naturally occurring substance in the body that plays a crucial role in maintaining skin hydration and elasticity. By introducing this hydrating substance into the lips through injections, the treatment provides a boost of moisture, resulting in plumper and more defined lips.

Benefits of injectable lip hydration treatment are natural-looking immediate results with minimal downtime.
•
•
•
Book your complimentary face assessment with Monica Berrange on 01268 833680 or DM us, limited spaces remaining for December.
#hyaluronicacid #facemed #nonsurgical #aesthetics #brentwood #billericay #facesbymon #enhanceyournaturalbeauty #aestheticsessex #nonsurgicalessex

Embrace the art of subtle transformation with non-

Embrace the art of subtle transformation with non-surgical injections using muscle relaxants 💉✨
•Botulinum Toxin works by temporarily relaxing the targeted muscles. In the case of brow asymmetry, the goal is often to adjust the activity of certain muscles to create balance and harmony.
•The effects of muscles relaxants take a few days to become noticeable, with full results typically visible within two weeks. The treatment provides a subtle and natural-looking correction to brow asymmetry.
•
•
•
Book your complimentary face assessment with Monica, limited December appointments remaining 🤍💜
#enhanceyournaturalbeauty #browtransformation #facesbymon #facemed
#subtlesymmetry #nonsurgical #aesthetics #ConfidenceBoost #essex #billericay #brentwood

Say goodbye to deep nasolabial and marionette line

Say goodbye to deep nasolabial and marionette lines and hello to a refreshed lower face with non-surgical injectable rejuvenation.
Prepare to look and feel your absolute best this upcoming festive season.
✨🥳💜🤩🎀
Monica Berrange offers complimentary new patient assessments, simply pop us a DM to enquire! #NaturalBeauty #YouthfulGlow #ConfidenceBoost #InjectableMagic #aesthetics #nonsurgical #facemed #aestheticsessex

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FACEmed LTD

FACEmed
Crays Hill
Billericay
Essex CM11 2XP

Registered in England & Wales Company No. 06682721

Opening Hours:
Mon – Fri 8am – 6pm
Sat 8am – 2pm

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