GDPR Agreement

It is mandatory to complete this form prior to your first consultation.

Please submit this form either digitally below, or print out and bring a hardcopy to your first appointment.

Download hardcopy

GDPR Patient Explicit Consent Data Protection Agreement

Patient Surname

First Name

House name/number

Street Name

City

County

Postcode

Phone

If acting in the capacity of a legal guardian, please state your name and role:

GP Name and Practice

Signed

I explicitly consent to being treated and the creation & storage of medical records concerning my treatment; I understand this may include details concerning medication, treatment & other issues affecting health conditions.

I understand that these records will be retained for 8 years after my last consultation in order to comply with the British Acupuncture Council requirements. I consent to access of my notes by all acupuncturists within these premises as necessary for acupuncture treatment.

I consent to my email address being used to email me marketing information in relation to the clinic newsletter (in addition to any use to contact me as recorded below for administration purposes).

I agree to pay any fees due at the end of each treatment, including any cancellation fee (up to level of appropriate fee) if I give less than 24 hours’ notice or do not attend without good reason.

Date

Thanks for submitting!