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 (*).

  • Please enter your full name
  • Please enter your UK Phone Number
  • Please enter your Email Address
  • Please enter your Address
  • Information about your Child

  • 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.
  • Date Format: DD slash MM slash YYYY