I understand that I am opting for an elective medical treatment/procedure/surgery.

I understand that the novel coronavirus, 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 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.

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.

I have been given or can ask for the option to defer my medical treatment/procedure/surgery 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/surgery.

• Due to the subjective nature of the treatment it is not possible to guarantee results
• Longevity of treatment results may vary between individuals.
• Patients can react differently to the same treatment
• List of possible risks and complications is not exhaustive.

I have read and understood the side effects and possible complications related to my treatment.

I have received a copy of the Patient Guide to Botox and Temporary Injectable Dermal Fillers.