Patient Registration

Patient Details

Title*

Mr
Mrs
Ms
Other

Patients Name*

First Last

Date of birth*

Occupation*

Address*

Street Address Address Line 2 City County Postcode Country

Mobile Telephone*

Home Telephone*

Email*

Enter Email Confirm Email

I agree to receive emails, including invoices and receipts, from Chelsea Medics.*

Yes
No

How did you hear about us?

Emergency Contact Name*

Emergency Contact Telephone*

If necessary are you happy for us to correspond with your NHS GP?*

Yes
No

NHS regular GP details

Please list your medical history*

Are you taking any medication?*

Yes
No

What medication are you taking?

Do you have any allergies?*

Yes
No

Details of allergies?

Data Protection Consent

Chelsea Medics 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?

General Contact

E-mail
Telephone
Post

Referral confirmation

E-mail
Telephone
Post

Appointment reminder

E-mail
Telephone
Post

Appointment booked confirmation

E-mail
Telephone
Post

Recall reminders

E-mail
Telephone
Post

Debt chasing

E-mail
Telephone
Post

Can we leave a voice Message on your phone

Yes
No

SMS / text message

Yes
No

Fees

Fees are payable at the time of consultation by debit, credit card or cash. In the event of non-payment, we reserve the right to charge your credit card with the outstanding amount including any pathology. 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 I undertake to settle any costs at the time after my appointment. *Applicable where the patient is under 18 years of age or does not have mental capacity. If not the patient, please state the relationship to the patient

Confidentiality and data protection

All patient data is handled in accordance with the Data Protection Act 1998 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. Chelsea Medics will share your non-medical information in relation to billing, processing, payments of collection of accounts. This extends to any person or organization they may involve achieving this. Chelsea Medics will employ appropriate measures to protect your personal data where this is the case. Chelsea medics 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.

By submitting this form, you are agreeing to the terms outlined in this registration form.*

Yes
No

Please click the "I'm not a robot" box below and then Submit

Patient Details

Data Protection Consent

Fees

Confidentiality and data protection

Address

102 Sydney Street, Chelsea, SW3 6NJ

Telephone

Email

[email protected]