Self Funding Patient Remote Consent Form Please fill out the form below. " Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth *(dd/mm/yyyy)Address *Address Line 1CityState / Province / RegionPostal CodePreferred Telephone Number *Alternative Telephone NumberEmail *CheckboxesPlease tick if you agree to us contacting you with service updates, information & newsletters & discount codes. We will not share with 3rd parties.G P Practice *Payment Method - Please confirm *Self FundingI understand that payment is expected prior to each treatment. I understand that I may be charged for missed appointments or appointments cancelled at late notice (less than 24 hours) 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 conditionsSteroid TreatmentEpilepsyCancerHeart/chest conditionPacemakerAnti-coagulant TherapyOsteoporosisMajor AllergiesDiabetesAutoimmune DisordersBlood DisordersHave you had any of the above? If Yes, please select.Female Patient OnlyGynaecological Conditions?HRT?Are you Pregnant?Are you currently seeing your Doctor for any other conditions? If yes please give details:What medication are you currently taking?Please tell us about any recent operations or past operations that might affect your current problemDate *Please check that all your information is correct before submitting.PhoneSubmit