NEW PATIENT REGISTRATION FORM

If you would like to register as a new patient, then please fill out our registration form and we’ll be in touch.

PATIENT DETAILS:

MEDICAL HISTORY:

DATA PROTECTION:

THE MAYFAIR GP is committed to protecting and respecting patient privacy and complying with data protection legislation and medical confidentiality guidelines. We have very strict rules and procedures in place to ensure that your information is kept safe and that your personal details are always kept safe. Please can you tick how you would like to be contacted?

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.

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.