Consultation Form Private GP Clinic

GP TELEPHONE CONSULTATION FORM
This form can also be used for a parent or guardian to give consent for treatment to be given to a young person.
THIS SECTION FOR COMPLETION BY THE PATIENT / PARENT / GUARDIAN
Address
Postcode
Date of Birth
Gender*
- Male
- Female
Your email
GP Practice (NHS) Name:
Location (town) of GP Practice:
Do you consent to us sending details of the appointment to the NHS GP Practice? *
- Yes
- No
Note : For child appointments, parental consent MUST be given to enable continuity of care within the NHS
Do you suffer or have suffered from any of the following:
- Epilepsy
- Undiagnosed swellings
- Diabetes
- High blood pressure
- Low blood pressure
- Depression / anxiety disorders
- Pacemaker
- Heart disease
- Hepatitis
- AIDS / HIV
- Eczema / Psoriasis
- Polycystic ovaries
- Osteoporosis
- History of cancer
- Asthma / Sinus disorders
How many unit of alcohol do you drink a week:
Details of allergies:
Details of operations or serious illnesses in the last 5 years:
Do you smoke?
- Yes
- No
Are you pregnant or breastfeeding?
- Yes
- No
Are you on any medication at present?
- Yes
- No
If yes to medication, name of medication:
Reason for your Consultation:
Note to Patient: The clinician should explain the proposed treatment and any alternatives. You can ask questions and seek further information. You have the right to refuse this treatment.
I am the:*
- Patient
- Parent
- Guardian
Consent for children

Everyone aged 16 or over is presumed to be competent to give consent for themselves, unless the opposite is demonstrated. If a child under the age of 16 has “sufficient understanding and intelligence to enable him/her to understand fully what is proposed” (known as Gillick Competence), then he/she will be competent to give consent for him/herself. Young people aged 16 and 17, and legally ‘competent’ younger children, may therefore sign this form for themselves, but may like a parent to countersign as well. If the child is not able to give consent for him/herself, someone with parental responsibility may do so on his/her behalf by signing accordingly on this Form. The doctor will discuss with you any queries you have.

We will send a letter to child's NHS GP for continuity of care.
I agree to email correspondence such as blood results, medical reports – please note our server is encrypted but your email provider may not have encryption.*
- Yes
- No
I understand Doctor Soin is the Medical Director and responsible for the Clinic and has financial interest in Private GP Clinic.*
- Yes
We’d be very grateful if you would let us know how you discovered our clinic by ticking one of the boxes below:*
- Internet
- GP Practice Waiting Room TV Screen
- Radio
- Recommended by friend / family
- Other

GP TELEPHONE CONSULTATION FORM

Your Company Name

A brief intro is always great. It's Helps people to identify your company.