Patient Registration | Belfast Skin Clinic

01 Patient Details

Title

Please specify

Full Name *

Date of Birth *

H&C Number

Gender

Please specify

02 Contact Details

Address *

Postcode *

Mobile Number *

Email Address *

03 Funding Details

How will you be funding your treatment? *

Self-funding Medical Insurance

Insurance Provider

Membership Number

Policy Number

Authorisation Code

I accept responsibility for costs not covered by my insurance *

Yes No

04 Next of Kin / Emergency Contact

Name

Relationship

Telephone Number

05 Consent to Contact on Your Behalf

I consent to Belfast Skin Clinic disclosing information to the individual named below, if they contact the clinic on my behalf

Yes No

06 GP Details

GP Name

GP Telephone

Practice Name

Practice Address

07 Marketing & Communication Preferences

I consent to being contacted by phone regarding my medical care

Yes No

I consent to being contacted by text or email regarding my medical care

Yes No

I consent to being contacted by letter at my home address regarding my medical care

Yes No

I consent to marketing or promotional offers being sent via text or email

Yes No

08 Use and Sharing of Medical Information

I consent to my medical information being shared with my GP

Yes No

09 Photography Consent

I consent to photographs being taken for my medical records

Yes No

I consent to photographs being made available to medical and nursing staff involved in my care

Yes No

I consent to photographs being made available to the NHS if required

Yes No

10 Medical Questionnaire

Do you have any allergies?

Yes No

Please list your allergies

Do you have a pacemaker or defibrillator?

Yes No

Please provide details

Do you take any blood thinning medication?

Yes No

Please list the medication

Do you have any bleeding or clotting problems?

Yes No

Please provide details

Please list ALL medication you are currently taking

Are you pregnant?

Yes No N/A

11 How Did You Hear About Belfast Skin Clinic?

Please specify

12 Patient Declaration

I confirm that the information provided is accurate to the best of my knowledge.

Signature of Patient / Guardian *

Sign here with your finger or mouse

Date

Patient Registration Form

Thank you