Due to the current restrictions, all patients must complete 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.

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

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 *