New Patient Registration - THE MAYFAIR GP

NEW PATIENT REGISTRATION FORM

Here at The Mayfair GP, our ethos is ‘the patient will see you now’!

We are a dedicated private practice that puts the emphasis on the patient, their convenience, our personal connection, and continuity of care.

With flexibility and convenience being key, we ensure we can be contacted by telephone 24/7 and we can visit you at home, your hotel or in your office.

If you’re looking for a discreet, yet personal service, please complete the enquiry form below and a member of the team will get back to you shortly.

PATIENT DETAILS:

TITLE *

FIRST NAME *

SURNAME *

DATE OF BIRTH *

ADDRESS *

MOBILE TELEPHONE NUMBER *

EMAIL *

OCCUPATION *

ARE YOU REGISTERED WITH AN NHS GP?

DO YOU HAVE AN NHS GP? *

GP PRACTICE (IF SO, PLEASE STATE)

NHS NUMBER

HOW CAN THE MAYFAIR GP HELP?

FEES:

Fees are payable at the time of consultation by debit, credit card or cash. A cancellation fee is charged on appointments cancelled with less than 24 hours’ notice.

AGREEMENT, DECLARATION & CONSENT:

I confirm that I have read, understood and accepted the terms and conditions set out in the registration form. I understand that I am personally responsible for any costs associated with my treatment and undertake to settle any costs at the time after my appointment.

PATIENT CONFIRMATION

CONFIDENTIALITY & DATA PROTECTION:

All patient data is handled in accordance with the Data Protection Act 7998. Your medical records are stored electronically and accessed only by authorised personnel. Disclosure of information may be made to appropriate health professionals when communicating about your presenting condition. It is common practice to write to a referring specialist or your NHS GP. If you would like us to do this, please inform your doctor.

THE MAYFAIR GP will share your non-medical information in relation to billing, processing, payments of collection of accounts. This extends to any person or organisation they may involve achieving this. THE MAYFAIR GP will employ appropriate measures to protect your personal data where this is the case. THE MAYFAIR GP has regulatory and or compliance obligations to share certain clinical data with various government and regulatory bodies for e.g CQC. This may include any personally identifiably clinical information.

PATIENT CONFIRMATION

DATE *

IF NOT THE PATIENT, PLEASE STATE THE RELATIONSHIP TO THE PATIENT: