Patient Consent Form Sep 26, 2020 PATIENT CONSENT FORM Patient consent to holding data and agreement to Podiatry treatment BLOCK CAPITALS PLEASE Patients surname: (required) Patients first name(s) (required) Date of birth: (required) Telephone No: (required) Email: Doctor's name: (required) Doctor's surgery: (required) In this clinic we pride ourselves on providing tailor made treatments that are patient specific. As such, occasionally during your initial consultation there may not be enough time to achieve all our goals. In this case we would ask you to return for a follow up appointment. If taken within two week there is a reduced fee. I will disclose all of my medical history to the best of my knowledge. I also consent to being treated by a Podiatrist. I confirm that I am aware the Podiatrist may use sharp medical instruments. We value and respect your privacy. We DO NOT share your information with any third party. Your information is only used for contact and appointment purposes and is subject to patient confidentiality. On our website the only information we collect from you, the client, is through our contact and booking form. The only information we collect is that which is provided by the patient or their guardian. By signing this or by ticking the online box, you are consenting to furnish us with the above information. Please see our website for full information. Additional information: Signed: (required) Date: (required) I agree to terms and condition: Once you have completed and submitted your Patient Consent Form you can now go back to BOOK YOUR APPOINTMENT.