COVID-19 Patient consent (1st visit since COVID-19 lockdown)

You will need to complete an online form before any attendance at CRGW while COVID-19 risks persist.

The first online form you will compete is the ‘1st visit questionnaire’.

For every subsequent visit to CRGW you will complete the ‘Repeat visit questionnaire’.

Guidance on COVID-19 risks in pregnancy from the Royal College of Obstetricians and Gynaecologists (RCOG)

COVID Consent: To complete before first visit to CRGW following lockdown

COVID Consent: 1st Visit Since Lockdown

Please complete this form prior to your first visit to CRGW following COVID-19 lockdown. For subsequent visits there is a shorter second form.

I am aware that I do not complete this form any earlier than 24 hours before my appointment*
Please complete this form no more than 24 hours prior to attending CRGW for your first time since covid19 lockdown.
Today's date*
DD slash MM slash YYYY

(dd/mm/yyyy)
Which clinic(s) do you wish to be seen at?*
Name*
Date of birth*
DD slash MM slash YYYY

(dd/mm/yyyy)
Telephone Number*
Email*
Enter Email Confirm Email
Partners Name (if applicable)
Partners date of birth (if applicable)
DD slash MM slash YYYY

(dd/mm/yyyy)
Partners telephone number (if applicable)
Partners email (if applicable)
Enter Email Confirm Email
Are you aware of the risks of COVID-19 in pregnancy?*
Before considering treatment, patients must be fully informed of the risks related to COVID-19 including potential increased risk when attending clinic (particularly if you travel on public transport). I am aware of the and the RCOG guidance on risks in pregnancy with COVID-19 and can access it to read it? www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/covid-19-virus-infection-and-pregnancy/ PLEASE SEE LINK AT TOP OF PAGE FOR RCOG GUIDANCE
I am aware I can choose to postpone my treatment*
With the knowledge of the potential COVID-19 risks in pregnancy I am aware I have the choice to proceed or postpone my treatment.
I am aware that CRGW may delay starting treatment if I am a high risk patient (ie those with medical risk, eg diabetes, hypertension, those receiving immunosuppressive medication).*
.
I am aware that initially patients will be prioritised?*
Initially CRGW aim to prioritise treatment for those patients whose treatments were stopped due to the start of the COVID-19 outbreak.
I am aware that PPE training will be provided to me if required?*
Only symtomatic patients will be required to wear PPE. Such patients will be trained in how to use it and additionally we will have wall posters and website instructions. PLEASE SEE LINK AT TOP OF PAGE FOR PPE GUIDANCE
I am aware my cycle may be cancelled / suspended if I am placed at high risk of COVID-19 infection?*
I am aware that if having IVF/ICSI that I may have to have all embryos frozen (no fresh embryo transfer) if I am placed at high risk of COVID-19 infection and or should the government change guidance as the result of a further peak in COVID-19 infections / deaths.*
I am aware of the financial implications of COVID-19 emergencies?*
Cancelled by myself: If I cancel my treatment because of self isolation, my cycle will be free of charge when I re-book other than the cost of my medication and any out of date blood tests since I will have paid for the treatment prior to my isolation. Cancelled by CRGW due to government / regulator intervention: If my treatment is cancelled by CRGW due to government or regulator intervention stopping their services my cycle will be free of charge when I re-book other than the cost of my medication and any out of date blood tests since I will have paid for the treatment prior to the cancellation. Cancelled by CRGW due to staffing : If my treatment is cancelled by CRGW due to staff illness due to the COVID-19 preventing staff performing treatments my cycle will be free of charge when I re-book since you I will have paid for the treatment prior to the cancellation and CRGW will pay 50% of your medication cost.
I will follow the COVID-19 code of conduct*
I will: 1) avoid unnecessary exposure to risks of Covid-19 infection at work and in private? 2) restrict interactions in line with government guidelines on social distancing and remaining at home, where appropriate 3) provide CRGW with updates regarding my health and wellbeing and whether I have infringed the code of conduct and been potentially exposed to Covid-19
Do you have any of the following symptoms?*
A high temperature (fever) A new continuous cough A loss of smell or taste (anosmia)
Are you at an increased risk of a severe illness from the coronavirus (COVID-19)? For example:*
1) Have had an organ transplant 2) Are having certain types of cancer treatment 3) Have blood or bone marrow cancer, such as leukaemia 4) Have a severe lung condition, such as cystic fibrosis, COPD or severe asthma 5) Have a condition that makes you much more likely to get infections 6) Are taking medicine that weakens your immune system 7) Diabetic 8) Are pregnant and have a serious heart condition
Have you (or your partner if applicable) returned from any countries outside of the UK within the last 14 days*
Have you returned from any countries outside of the UK within the last 14 days?
Have you (or your partner if applicable) had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?*
Have you (or your partner if applicable) been in close contact with anyone who has traveled within the last 14 days to any country listed as a COVID-19 infectious area?*
Have you (or your partner if applicable) experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)*
Are you (or your partner if applicable) shielding from COVID-19 or live with people who are shielding?*
*Shielding is when people vulnerable to COVID-19 self isolate
I am aware that as contact tracing technology becomes available (COVID-19 smartphone app) CRGW encourage patients to use it.*
I am aware that CRGW must consider all cases for any risks of treatment while the COVID-19 pandemic persists while minimising impact on NHS resources (eg. OHSS, multiple pregnancy risks)*
I am aware that NHS services such as Early Pregnancy Assessment Units may have different policies during Covid-19 should I require access to them.*
I am aware that if I suffered Covid-19 which required respiratory support (e.g. a respirator) CRGW will require evidence of a favourable assessment from a relevant clinician prior to starting treatment.*
Electronic signature (Patient)*

My electronic signature below confirms I have read and understand the COVID-19 specific information above.
Electronic signature (Partner - if applicable)

My electronic signature below confirms I have read and understand the COVID-19 specific information above.
FORM COMPLETED BUT FURTHER CLARIFICATION REQUIRED*

PLEASE INITIAL THE BOX ABOVE. Clarification is required prior to your appointment at CRGW by our staff due to your answers provided. Please submit your form by clicking below.
Email
This field is for validation purposes and should be left unchanged.