Patient Registration Form

Title

First Name

Surname

Preferred Name

Date of Birth

Contact Details

Home Telephone

Mobile Number

Address

Address Line 1

Address Line 2

City

County

Postcode

Parent's name (on child under 15 years of age) – Legal representative

Legal Guardian’s name

GP Name

Surgery Name

Surgery

Address Line 1

Address Line 2

City

County

Postcode

How did you hear about us?

Please note that payment in cash or via bank transfer, on a self-pay basis, is required at the end of the consultation.

GP Letter/ Photographs

After your consultation our practice normally is to write to your GP for good communication.

I am happy for a letter to be sent to my GP

I do not want Kovacs & Partners to send a letter to my GP

We may take a photograph of your foot to keep on record as we find this very useful to record changes over time

I am happy for photographs to be taken

I do not consent for photographs to be taken

Appointment Commitment

On making an appointment with me at Kovacs & Partners we are all agreeing to honour that commitment. The digital management software will send you a reminder about your booked appointment shortly after you booked in and 48 hours prior to the session.

At times things will get in the way and it will be necessary to reschedule appointments. I promise to give you as much notice as possible.

If you are unable to make your appointment, I would request that you let me know as soon as possible so that I can offer an appointment space to another patient.

Please write me a short message via SMS / WhatsApp or a short e-mail as during the day I may not have the chance to pick up the phone or listen to voice messages.

USE OF PATIENT INFORMATION

To receive continuity and quality of care this information is recorded and may be shared with other members of the health care team involved in your care. We do not share your information with anyone who is not directly involved in your care.

PLEASE READ AND SIGN TO:

Confirm you understand our appointment confirmation.

Confirm the information you have provided is accurate and that you understand this information will be held securely to ensure safe and effective care.

CONSENT FOR TREATMENT

Professionals are legally and ethically obliged to obtain informed consent prior to any treatment. At the first session, the professional will ask further questions and assess your condition. All necessary information and details will be discussed with you so that you can make an informed decision.

You will be given time to consider the treatment options and what is suitable for you - Your consent can be withdrawn at any time

A professional may use sharp instruments and other equipment that may cause minor damage to the skin surface

I accept the Terms and Conditions and Privacy Policy

Your Signature (type in your forename and surname as entered in the application as your digital signature):

Parent signature (with parental responsibility) (type in your forename and surname as entered in the application as your digital signature):

Young Person Signature (age 15 plus) (type in your forename and surname as entered in the application as your digital signature):

NOTE: Your Computer IP Address, along with date and time will be recorded when you click 'Submit'

I am happy to receive key patient information

I do not want to receive key patient information