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.

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. 

 

Stafford Skincare - Lichfield

Dr. Anne Ward

Consultant Dermatologist

Form 1: Registration Form

Please confirm if you have had a Covid vaccination? Please tick one choice

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 

We ask that a Consent Form is completed if you are sending photographs or if you are attending an on-line consultation. Photographs should be sent to the secure email address: anneward@protonmail.com. On-line video consultations use a secure healthcare platform called Doxy.me.

   

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

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