I have read and understood the pamphlet ‘Your First Visit’ and consent to an appropriate physical examination.

Are you happy to receive emails about holiday opening times, changes in the clinic, offers and updates?*

Yes

Upon completion of the Patient Details Form, Data Protection Form, all paper files and information therein maybe electronically scanned and stored on computer file for as long as the patient remains a patient of the clinic and thereafter for a period of 7 years. I the undersigned (or authorised guardian) acknowledge that I have read the Data Protection Policy above and do hereby give consent to the practitioner/Chiropractor to maintain records for the purpose outlined within the policy.*

Yes

Signed

Name

Date

If you are under 16 years of age, this consent should be signed by a parent or legal guardian.

Signed (parent/guardian)

Name (parent/guardian)

Date

Please do not hesitate to ask one of our members of staff for the full version if our data protection policy.

CONFIDENTIAL

New Patient Registration

Nature of work and duration involved per day:

Have you had any of the following conditions or symptoms?

I have read and understood the pamphlet ‘Your First Visit’ and consent to an appropriate physical examination.

Monday - Friday

Telephone

Email

Address

Apprenticeship Applications