PLEASE ONLY FILL THIS FORM IN IF YOU HAVE A SCAN BOOKED AT ONE OF OUR CLINICS AND HAVE BEEN ASKED TO COMPLETE ONE

SECTION 1: Consent Form

Name

Date of Birth

Address

Tel Home

Mobile

Clinic Location & Date of Clinic

GP name/surgery address

PLEASE READ THE FOLLOWING STATEMENTS AND DECLARATIONS CAREFULLY BEFORE PUTTING YOUR INTIALS BY EACH

I understand that I will need to undress relevant body areas as required for a bone health assessment. I have the right to refuse to do this at any time

I consent to a physical examination by Mr Nick Birch FRCS (ORTH) Consultant Spinal Specialist and other staff of OsteoscanUK as appropriate. If I am uncomfortable with being examined 1-on-1 I can request a chaperone. I can bring my own chaperone if I wish

I understand that I may be exposed to forms of medical latex within the consulting rooms of OsteoScanUK, and confirm that I have no allergies that would be adversely affected by this.

I understand that I should inform the staff of OsteoscanUK if I have any other significant allergies

I understand that I should inform the staff of OsteoscanUK if I have any life-assisting electronics implants (pacemakers, defibrillators etc

I agree to accept my scan results via a non-encrypted email

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)

Name

Date

SECTION 2: Data Protection Consent Form

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.

I consent to all details, collected by the completion of the registration forma, being retained by OsteoscanUK in accordance with the data protection policy

I consent to all third party correspondence, received by OsteoscanUK being retained in accordance with their data protection policy

I consent to OsteoscanUK corresponding with third party companies (GPs, consultants therapists, insurance companies etc) as part of my treatment process unless I explicitly request so. In this case, I will fully inform OsteoscanUK of who should not be contacted.

To enable OsteoscanUK to maintain accurate and up-to-date records, as necessary with GDPR compliance, I will inform OsteoscanUK with any relevant changes as soon as possible.

Name

Select a date

For patients <16 years, a parent/guardian is required to sign

The personal data collected above will be used by Osteoscan UK Ltd for health care purposes, but will also be stored by WIX in the USA. Under Article 6 and Article 9 requirements of fair processing (Article 6(a) and Article 9(2)(a), by ticking this box you are agreeing to the terms & conditions

Thanks for submitting!