Patient consent Form.

STROUD SPORTS CLINIC Ltd.

Patient Consent Form and Data Protection Policy

Payment for services provided

• We accept cash and all major credit and debit cards. Patients are politely requested to settle their fees after each visit. 
• We regret that unless 24 hours notice is given in cancellation, a full charge may be made. 
• Most medical insurance policies will cover Chiropractic/Physiotherapy and Sports Therapy treatments offered by this clinic. As each company has its own criteria we politely request that the patient settles treatment fees after each visit and make their claim in the appropriate way direct to the insurer for reimbursement. It is helpful to know, however, if you do plan to claim through private insurance. Please tell your practitioner if you are planning to do so. 
• I agree to the terms above and conditions for fees.
  Data protection
  Under the Data Protection (1998) Act, we are required to advise our patient(s) on our Data Protection Policy.
  As part of the Patient Record, this clinic is required to retain information for the purpose of the consultation for treatment, recording subsequent treatments, and for use by third party medical practitioners only, at the request of the patient, in writing.
  Upon completion of the Patient Details Form, Data Protection and Consent Form, all paper files and information therein may be electronically scanned and stored on a computer file for as long as the patient remains a patient of the clinic, and thereafter a period of 7 years. Alternatively paper records will be retained for the same period.
  All the information provided will be treated as confidential, and will not be given to any other person(s)/organisation(s) without written consent of the patient concerned.
  Information held both manually and electronically in files is accessible only by staff of the Clinic that are directly involved in the data entry and processing of patient records.
  I the undersigned* acknowledge that I have read the Data Protection Policy (above) and do hereby give consent to the Practitioner to maintain records for the purposes outlined within the policy. I also consent to the sharing of my treatment records with other practitioners at Stroud Sports Clinic Ltd if they become involved with my ongoing treatment.
  Consent to examination and treatment:
  Occasionally it may be necessary to contact your GP and inform them of findings for which your permission is needed. I consent to an appropriate physical examination and give authorisation for my GP to be contacted as necessary.
  I have been given my Report of Findings regarding my condition. I have been advised of, and understood, the possible risks of treatment and had all my questions answered to my satisfaction. I consent to treatment as outlined.

Name (PLEASE PRINT)

.............................................................................................................................................................

Date .....................................................................................................................................

Signed .....................................................................................................................................

Please print and provide this signed form to your practitioner.