Patient Consent Form printable pdf download

Patient Consent Form

PATIENT CONSENT FORM

Name ____________________________________________________ Case ______________

DATA PROTECTION POLICY

Under the data protection (1998) Act, we are required to advise our patients on

our Data Protection Policy.

As part of the patient record, this Clinic is required to retain information for the

purpose of consultation for treatment, recording subsequent treatments and for

use by third party medical practitioners only, at the request of the patient, in

writing.

Upon completion of the patient Details form, Data protection and consent form,

all paper files and information therein may be electronically scanned and stored

on computer file for as long as the patient remains a patient of the clinic; and

thereafter for a period of 7 years. Alternatively paper records will be retained for

the same period.

All information provided will be treated as confidential and will not be given to

any other person(s)/ organisation(s) without the written consent of the patient

concerned.

Information will be held both manually and electronically in files accessible only

by staff of the clinic who are directly involved in the data entry and processing of

patient records.

I the undersigned (or authorised guardian)** acknowledge that I have read the

Data Protection Policy (above) and do hereby give consent to the practitioner /

chiropractor to maintain records for the purpose outlined within the policy.

Signature: ____________________________________________________

Date ________________________________________________________

** For patients under the age of 16, a parent/guardian is required to sign.

PAYMENT

I fully understand that payment is entirely my responsibility, even if claiming

through insurance.

Signature: ___________________________________________________ Date ____________

Patient Consent Form