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Nurse Form

Health Declaration Form

Please ensure to fill out this form prior to your visit.

Title

First Name

Surname

Email

Date of Birth

Phone

Address

What is your medical problem?

If you answered yes, please provide your NHS GP's details

if yes, would you like us to inform them of any care you undertake with us?

Please list your medical history

What medication are you taking?

Do you have any allergies?

DATA PROTECTION:

We are committed to protecting and respecting patient privacy and complying with data protection legislation and medical confidentiality guidelines. We have very strict rules and procedures in place to ensure that your information is kept safe and that your personal details are always kept safe. We will however share your non-medical information in relation to billing, processing, payments of collection of accounts. This extends to any person or organisation they may involve achieving this.We also have regulatory and compliance obligations to share certain clinical data with various government and regulatory bodies. This may include any personally identifiably clinical information.
Please can you tick how you would like to be contacted?

AGREEMENT, DECLARATION & CONSENT:
I confirm that I have read, understood and accepted the terms and conditions set out in the registration form. I understand that I am personally responsible for any costs associated with my treatment and undertake to settle any costs at the time after my appointment.

Select a date

Initials

I declare that the info I’ve provided is accurate & complete

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