Patient Agreement Form (Page 2 of 2) in pdf

Patient Agreement Form Page 2

Mobile phones

I agree to either switch my phone off or ensure it remains on silent at all times whilst being within

the practice. When making and receiving phone calls I must stand outside that practice to respect

other patients around.

Policy on seeing minors

I understand that all children up to the age of 16 must be accompanied by an adult to see any clinical

staff member. I understand that the confidentiality policy gives any patient over the age of 16 to

retain any of their test results and can be given to the parent only if permission is clearly stated by

the patient in their records or a staff member has received verbal consent from the patient.

Private Fees

I understand and accept that the surgery is asked to write letters and complete forms on behalf of a

patient, which is not covered under the NHS. I agree that in such circumstances, there will be a

charge, which may vary depending on type of request made. Please contact the surgery or speak to a

member of staff at reception for details of our fees, before leaving your request. I understand that in

most cases, a doctor’s appointment is not necessary when the completion of a form is needed. I

agree with the surgeries policy, that I must leave the form with a member of staff at reception along

with the correct payment before completion and that the surgery cannot provide any further

change. I understand that I must allow at least 7-10 working days before the successful completion

of a form.

Please state your full name _________________________________________________

Signature___________________________________________ Date_____/_____/_____

Patient Agreement Form Page 2