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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. Data Protection Bounce values you as a client and complies with the new GPDR legislation to protect your data. We will process the data given above according to our privacy policy- please see below.