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Name *
i.e 14/11/1990
If claiming on insurance please fill in
Payment Details
16 digits across middle of card
3 digits on reverse of card
Card Type *
Consent for Examination & Treatment
I understand that any diagnostic material recorded by this clinic remains the property of the clinic and will only be released to other parties with my prior agreement, and that all clinic files are subject to internal and/or external audit by a qualified and appointed person(s). In case of treatment to a minor, or a patient who is recognised to have diminished intellectual capacity, this consent is to be signed by either parent or legal guardian, this fact being appropriately noted below. I hereby consent to a physical examination by a qualified clinician in order to establish a diagnosis and to any subsequent treatment and/ or rehabilitation prescribe. Complaints If you have a complaint you should tell a member of staff. If you are not satisfied, we would ask you to put any complaints in writing to the email address Change Of Details Please keep us informed of any change of address, email address, contact numbers, bank account details for payment and any other information relevant to your membership. Data Protection We keep to the Data Protection Act 1998. We will deal with all information we hold about you in line with our privacy policy which is on our website. If you want to know what information we hold about you, or if you want to correct any information we hold, please let us know.