PRIVACY NOTICE CONFIRMATION FORM

Please fill and submit this form prior to your scheduled appointment.

This website makes use of several layers of security to ensure that your information is sent to us securely.

All mandatory fields are marked with an asterisk (*).

Full Name of Parent or Carer*

Please enter your full name
Your Phone Number*
Please enter your UK Phone Number
Email Address*

Please enter your Email Address
Your Address*

Please enter your Address
Information about your Child
Please enter the full name of your Child
Your Child's Address*

Please enter your Child's Address
Privacy Notice Information
How information about you and your child will be used by this Practice.
- The information about you and your child will be used to request for further assessments, make appropriate referrals and/or share relevant clinical and/or service information about your child with you and other professionals.
- The information we hold about you and your child may be anonymised to enable us carry out relevant audits or research in the work of this practice.
- The information we hold about you and your child will be used to communicate with insurance companies and appropriate agencies as necessary to enable prompt processing of any medical fees.
Do you agree to the Privacy Notice Information above?*
- I Agree
- I Do Not Agree
Date of Form Submission*
DD slash MM slash YYYY

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