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NHS Funded Patient Remote Consent Form

Book an Appointment
Name
(dd/mm/yyyy)
Address
Email Consent
NHS Referral
I understand that my doctor will be informed of my attendance and progress. I understand that it is my responsibility to attend my appointment and that if I fail to attend or give adequate notice (24 hours) I may be discharged and my doctor notified.
Clear Signature
Signature required
Clear Signature
Signature required
Medical Checklist.
We ask these questions for your safety. Please contact us or ask at your appointment if you have any queries or are uncertain.
Pre-existing medical conditions
Have you had any of the above? If Yes, please select.
Female Patient Only
Clear Signature
Please Sign
Please check that all your information is correct before submitting.

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We’re so sorry to hear that you aren’t happy with our service. Your feedback is really important to us and we do all we can to make sure we are constantly improving. Please leave your feedback for us below and we’ll get back to you to see what we can do to resolve any issues you may have.

Write Your Review

We’re so sorry to hear that you aren’t happy with our service. Your feedback is really important to us and we do all we can to make sure we are constantly improving. Please leave your feedback for us below and we’ll get back to you to see what we can do to resolve any issues you may have.

Write Your Review

We’re so sorry to hear that you aren’t happy with our service. Your feedback is really important to us and we do all we can to make sure we are constantly improving. Please leave your feedback for us below and we’ll get back to you to see what we can do to resolve any issues you may have.