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NHS Funded Patient Remote Consent Form

Please fill out the form below.

 

(dd/mm/yyyy)
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.
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.
Have you had any of the above? If Yes, please select.
Please check that all your information is correct before submitting.