Registration Form | Consent Form | LichfieldFaceClinic

Clinic Forms

Please go to the "Contact" page if you would like to arrange an appointment or ask a question. The Contact Form is shorter and is all that is needed for the first contact.

 

This page has 3 Forms. You will be asked to fill out the relevant Form when booking your appointment. Everyone will need to fill out Form 1 - the Registration Form. People arranging an on-line video consultation, or sending photographs, will also need to fill out Form 2.

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Form 3 is a screening checklist to be completed within 48 hours prior to your appointment, if you are attending the Clinic.

 

Before submitting your Forms, click here to read our Privacy Notice to find out why we need to collect this information from you, and what we do with your information. 

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There is a very small chance that an on-line submission may be compromised in transit. Please make sure that you feel comfortable sending the required information on-line. If you prefer to print off a paper copy of the Forms that you can fill out at home, and then post back to the Clinic - please let us know by email, and we will send you the relevant Forms. 

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Stafford Skincare - Lichfield

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Dr. Anne Ward

Consultant Dermatologist

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Form 1: Registration Form

Please confirm if you have had a Covid vaccination?

Thank you for submitting your Registration Form. Please check your Junk Box if you do not receive a reply within 48 hours.

Form 2: Consent Form for an On-Line Consultation 

An on-line video consultation, along with good quality photographs, is a good way to treat skin problems such as acne or melasma. It is also used to assess people prior to a cosmetic procedure or skin surgery, as less time is spent in clinic, helping to reduce the risk of Covid-19 transmission.  

 

There are some limitations to using an on-line video consultation. The main problem is that sometimes the image resolution of the video is a bit blurry. This means that it may not be possible to make a definite diagnosis if the skin rash is subtle. Likewise, it may not always be possible to distinguish a benign skin lesion from a skin cancer. This is why you are asked to send in photographs before your consultation as this helps in making an accurate diagnosis. 

   

Please click each of the boxes below to confirm that you have read and that you understand the information. 

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Thank you for submitting your Consent Form for a on-line Consultation

Form 3: Pre-Appointment Screening Checklist 

Please tick the relevant boxes. Please send this Form within 48 hours before your appointment. 

Have you, or a close contact, experienced any of the following symptoms within the last 14 days?
Have you, or a close contact been diagnosed with Covid in the last 14 days?
Have you, or a close contact, travelled abroad, or attended a public event within the last 14 days?

Thank you for submitting the Screening Checklist Form