Lido Medical Practice - Patient Registration Form

8. Medical History

Do you suffer from any Allergies?:

Yes

If Yes please provide details:

Do you currently take any medication?:

Yes

If Yes please provide details:

Do you suffer from any significant ongoing medical problems?:

Yes

If Yes please provide details:

Have you had any serious illness or operations in the past?:

Yes

If Yes please provide details:

9: Patient Declaration and Personal Data Statement

Your personal information:

The information collected on this application form will be used by Lido Medical Practice (hereafter the ‘Practice’) for the purposes of healthcare

related services and practice administration.

Personal data relating to you will be retained by the Practice for the purposes of providing you with medical and healthcare related services both in

the Practice and where appropriate at the premises of other healthcare providers. This may require your personal data including relevant details of

your medical history to be shared with other healthcare providers for the purpose of referrals and for other lawful purposes related to the Practice

procedures.

Your declaration to us:

I understand that the Practice has the right to accept or decline my registration application at any time.

I understand that by attending a consultation with a GP or other healthcare professional of the Practice I accept the Practice terms of

service and fee schedule issued and displayed in the Practice premises and as amended from time to time.

I hereby agree to pay the consultation fee prior to seeing a GP or other healthcare professional of the Practice and agree to pay all

treatment given by the Practice at the time of the treatment thereafter.

I give my express permission for the Practice to request information including my medical records from my registered GP and I agree

to reimburse the Practice for all charges and disbursements relating thereto for being provided with such information.

I confirm that all the information I have given in this registration form is accurate to the best of my knowledge. Furthermore I

understand it is my responsibility to advise the Practice in writing of any changes made in respect of my personal information.

Signed*:

Print Name:

Dated:

* If patient is a under the age of 16, this form must be signed by the parent/guardian detailed on first page

Please note: Jersey is not connected to the NHS or any other health authority.

For LMP Use Only

Received By:

On System By:

EMIS Number:

PRF-VISITOR V.001 | Page 2 of 2

Lido Medical Practice - Patient Registration Form - Visitor Page 2