PLEASE READ THE FOLLOWING STATEMENTS AND DECLARATIONS CAREFULLY BEFORE PUTTING YOUR INTIALS BY EACH
The information I have provided is correct and not intended to mislead. I have read, understood and completed this form in full and have asked any questions that I may have prior to signing and Understand that my GP may be informed of my visit, unless I specifically request otherwise. In exceptional circumstances involving serious illness, a threat to life or similar, OsteoscanUK may decline to agree to this request.
By signing this form I and consenting to all examinations provided by OsteoscanUK staff and/or associates.
I accept complete responsibility for all personal/family/business/corporate (delete where appropriate) interactions with any health insurance schemes that I may be using to help pay for part, or all, of my fees and acknowledge that I am responsible for any debit of shortfall if the insurance company does not remunerate the treatment in full or in part. In these circumstances I shall be liable for any outstanding accounts under my name and will incur the costs of recovery the debt (to include internal administrative and external agency fees) should it be passed to a debt recovery agency.
To be signed by the patient (if the patient is <16 years of age, this form is to be signed by a parent/guardian)
Under the General Data Protection Regulation 2018, we are required to advise our patients on our Data Protection Policy.
As opart of the patient record, this clinic is required to retain information for the purpose of consultation for treatment and recording subsequent treatments. This is collected by way of registration and medical consent forms, correspondence from external practitioners in either paper of e-format and imagery in electronic format.
Upon completion oof the registration, medical and data protection consent forms, 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 7-10 years. Full descriptions can be found in our company policy and are available on request for reference.
All information provided will be treated as confidential and will not be give to any other person(s)/organisation(s) external to OsteoscanUK without written consent of the patient concerned.
Information may be held both manually and electronically in files accessible only by staff of the clinic who are directly involved in the treatment, data entry and processing of patient records.
For patients <16 years, a parent/guardian is required to sign