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Self Funding Patient Consent Form

Please fill out the form below.

 

(dd/mm/yyyy)
I understand that payment is expected at each treatment. I understand that I may be charged for missed appointments or appointments cancelled at late notice (less than 24 hours)
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Signature required
Clear Signature
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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.
Clear Signature
Signature of person with parental responsibility / person legally entitled to sign on behalf of a person who lacks capacity
Please check that all your information is correct before submitting.