Patient Registration & Declaration - The Faringdon Wellbeing Clinic

SECTION 1: To be completed by everyone

First name *

Last name *

Date of birth *

Email *

SECTION 2: REGISTRATION - To be completed only if you are a new patient or your details have changed.

Address

Postcode

Home telephone

Work telephone

Mobile telephone

Emergency contact number

GP name

GP address

Who referred you?

Insurance company

Insurance reference number

Have you been to the clinic before?

Yes

No

How did you heare about this clinic?

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

Home phone

Mobile phone

Email

Preferred time of contact

AM

PM

Evening

I consent to be contacted by The Faringdon Clinic. I understand I may withdraw my consent at any time. *

I agree

I certify that the above information is correct on this date *

I agree

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