Patient Registration

Patient Details:

Name:
*In accordance with the Unsolicited Electronic Messages Act of 2007, we ask that by leaving your email address, you give us permission to contact you periodically.
If applicable.
(If known)
If applicable.
Address:

Emergency Contact:

Address:

General Practitioner Details:

(If known)

All consultations and treatments are kept completely confidential, and your privacy is our top priority; however…

In the unlikely event of any medical emergencies, it may be necessary to contact your Doctor or next of kin. Do you consent to a staff member contacting your GP/next of kin in such an emergency?
After specific medical consultations and procedures, it may be appropriate to communicate in writing to your named GP. Do you consent to us writing to your GP?
For your records, we take photographs of before and after treatments. Photographs will be used for comparison results only. Please confirm whether you give consent for your photos to be taken.

Medical History:

(e.g. high BP, heart disease, diabetes, cancer, blood clotting disorder, stroke etc)
Immediate family e.g. siblings, parents, grandparents.
Do You Have a GP Referral?
Smoking History
Please pick one.
Procedures You May Be Interested In:
Pick all that apply.
Clear Signature
Please sign in the box below using your mouse, finger (on touch devices), or stylus. By signing below, I confirm the information I have provided is accurate to the best of my knowledge.