If claiming on insurance please fill in
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.
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 email@example.com.
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.
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