Patient Agreement Form printable pdf download

Patient Agreement Form

ase read through ALL the information below before signing. The surgery will

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take a copy and will keep it in your personal records to show you agreed to the

practices terms and conditions.

Disclosure

I the patient agree to disclose all material facts regarding my health to my general practitioner and

other clinical staff.

Treatment of staff

I agree with the policy of zero tolerance of abuse towards all staff, also not to behave in an abusive,

threatening or otherwise aggressive manner with any member of the practice. I Acknowledge the

right of the practice to remove me from the surgery list without appeal should I behave in a manner

prohibited.

Repeat prescription

I agree to request any repeat prescriptions two full working days before collection and give three full

working days when a bank holiday arises. I understand I can only request prescriptions within the

surgery by filling out a form or online, I cannot request over the telephone.

Complaints

I understand that if I am dissatisfied with the services at Herschel Medical Centre, I must speak to a

senior member of staff or write my complaint in writing.

Confidentiality

Herschel medical centre declares that all matters and information pertaining to the patient shall not

be released without the patients consent.

Appointments and emergency appointments

I agree to attend on time for all appointments that I book with the practice and cancel any I cannot

attend in advance but contacting the surgery or personally information the member of staff at

reception. I acknowledge that if I arrive late for an appointment, I may be asked to rebook for

another time. I agree to only use emergency appointments for medical conditions that require

immediate treatment.

Home visits

I shall only request a home visit from the practice under circumstances where I cannot physically

attend the practice for an appointment.

Chaperones

I understand that a chaperone is available for any consultation at any stage and that I can request

this via the reception staff or any clinic staff.

Patient Agreement Form