Patient Registration and Privacy Agreement Form Patient Details Title (required) —Please choose an option—MasterMissMrMrsMs First Name (required) Last Name (required) Gender (required) —Please choose an option—MaleFemale Date of Birth (required) Contact Details Name of parent if under 16 years old Address Address Address City County Postcode Home Phone* Mobile Phone* Email* *You do not have to tell us your phone or email but it will help us to contact you. GP Details Name of GP Practice Name What is the reason for your consultation? Suspected allergiesSevere allergic reactionAsthmaHay feverAllergic rashes or eczemaPeanut immunotherapyHay fever immunotherapyOther Please give a short outline of your reasons for consulting Preferred Payment Method Self PayPrivate Medical Insurance Self pay - We will invoice you after the appointment by email. We accept credit cards by Paypal or over the phone to our accounts team, or by bank transfer or cheque. PMI - Please provide details of your policy as we can use these to invoice your insurer directly. If we are unable to invoice your insurers directly we will invoice for you to pay and then liaise with your insurers. Private Medical Insurer (PMI) PMI Account Number PMI Authorisation Code *We will invoice you after the appointment by email. We accept credit cards by Paypal or over the phone to our accounts team, or by bank transfer or cheque. **Please provide details of your policy as we will use these to invoice your insurer directly. How we use your information to provide you with healthcare This practice keeps medical records confidential and complies with the General Data Protection Regulation. We hold your medical record so that we can provide you with safe care and treatment. We will also use your information so that we can check and review the quality of the care we provide. This helps us to improve our services to you. We will share relevant information from your medical record with other health or social care staff or organisations when they provide you with care. For example, we will share information with your family doctor (GP) or if we refer you to another hospital specialist, or we will send details about your prescription to your chosen pharmacy. For more information on how we share your information with organisations who are directly involved in your care can be found on Practice Privacy Notice (PPN) on our website. You have the right to object to information being shared for your own care. Please speak to the practice if you wish to object. You also have the right to have any mistakes or errors corrected. Full details of our Practice Privacy Notice can be found on our website (www.allergyheathcare.co.uk) or please contact us and we can send you a copy just email info@allergyhealthcare.co.uk Privacy Agreement Phone Messages We hold telephone numbers for you in case we need to contact you about your appointment. We also send routine SMS text message appointment reminders. We don’t use text message marketing but you can opt out anyway below. I would like to receive marketing updates by SMS text message —Please choose an option—YesNo Email We have an email address for you in case we need to contact you about your appointment or invoice. We will only send clinical information by post or encrypted email. You can opt out of receiving appointment information by email below. I would like to receive appointment information by email —Please choose an option—YesNo Your Privacy I agree to the terms and conditions of our service —Please choose an option—YesNo I agree to the terms and conditions of our practice privacy notice (PPN) https://www.allergyhealthcare.co.uk/practice-privacy-notice/ —Please choose an option—YesNo
