Choice Healthcare Services

Title: *

Name: *

Date of Birth:

Occupation:

Address: *

 

 

Postcode: *

Home Phone: *

Email: *

Clinic: *

Treatment: *

Date: *

I give permission for Choice Healthcare Services Ltd. to keep my personal
and medical details on record, in paper and computerised form.*

I give permission for Choice Healthcare Services Ltd. to contact my NHS
doctor for further medical information if considered necessary.*

I want my NHS GP to be informed of the consultation(s).*

Doctor: *

Practice: *

Address: *

 

 

I understand that Choice Healthcare Ltd. is registered under the Data Protection Act 1984 and that all my personal and medical information will be treated in the strictest of confidence.
Please tick if you agree*

please tell us how you heard about Choice Healthcare Ltd. (Please tick one or more boxes)*

Please tick yes or no and give brief details if possible