Due to the current restrictions, all patients must complete sections 1 and 3 of this form before attending the clinic for a treatment. Section 2 should be completed ONLY if you’re a new patient or if any of your details have changed.

Fields marked with an * are obligatory.

Patient Registration & Declaration

SECTION 1: To be completed by everyone

SECTION 2: REGISTRATION - To be completed only if you are a new patient or your details have changed. Otherwise, go straight to SECTION 3.

Have you been to the clinic before?

Guarantee of payment

I will provide details for invoicing. I understand that I am liable for any excess payments, or for the full cost should the invoice remain unpaid after 60 days.

Cancellation Charge

There may be a charge if less than 24 hours' notice of cancellation is given unless this is due to onset of fever.

Patient/Client Consent to Contact (General Data Protection Regulations)

Preferred method of contact
Preferred time of contact

SECTION 3: To be completed by every patient

Have you had a fever or new persistent cough or other suspected COVID-19 symptoms in the past 14 days? *
Have you been in contact with anyone who has COVID-19 or the symptoms of the disease in the past 14 days? *
Have you had any loss of taste or smell in the past 14 days? *
I consent to be contacted by The Faringdon Clinic. I understand I may withdraw my consent at any time. *
I certify that the above information is correct on this date *