Patient Registration Form

GUIDANCE

Please have a photo ID (passport or driving license) ready before starting to complete this form. In the case of a child aged less than 16 years, please provide ID of a parent.

Please use the exact name (spelling, no typographic errors) and DOB used to make your booking, in order for the system to match your form with your account.

Please also complete the form in the name of the patient who is being seen.

Personal Details

Title

First Name

Last Name

Prefered Name / Nickname

Date of Birth

Biological Sex

Gender

Prefer to self-describe gender:

Contact Details

Address Line 1

Address Line 2

City

County

Postcode

Country

Mobile No.

Medical History

Do you have any medical problems or have you had any surgery?

Yes

If yes, which one(s)?

Do you take any regular medication?

Yes

If yes, which one(s)?

Do you have allergies to any medication?

Yes

If yes, which medication?

The clinician should explain the proposed treatment and any alternatives. You can ask questions and seek further information.

I understand

Do you require any adjustments for your appointment?

If yes, then please describe what adjustments your require:

Cancellation Terms

Should you need to move or cancel your appointment, we request that you email us with as much notice as possible. Alternatively, you can amend bookings from your bookings portal.

If you cancel up to 24 hours prior to your appointment you are eligible for a full refund, by emailing: refund@privategpclinic.co.uk

If you cancel with less than 24 hours notice or do not attend your appointment, you will not be offered a refund (i.e. the cancellation charge is the full fee)

Please click to confirm that you have read and understand the cancellation policy.

Yes

Declaration & GP Details

All patients under the age of 18 MUST consent and provide NHS GP details. This is because it is mandatory for us to send a letter to the child's NHS GP if any medication is prescribed, for continuity of care.

I agree to a letter being sent to my NHS GP and understand that a letter will only be sent automatically if I have been issued with a prescription.

Upload Identity Documents

I am the:

Photo ID (e.g. Passport, Driving License)

Choose File

Enter an optional message such as your reason for attendance