ELECTRONIC CONSENT

Blue Eye Healthcare believes in giving you more hands on time and less administration on your visit, as well as reducing the environmental impact of paper usage. This also gives you time to consider the consent process and ask any questions. 

Please read the information sheet below and if happy, complete the electronic consent submission. (Paper consent available too in clinic.)

 

PATIENT DETAILS Name *
PATIENT DETAILS Name
DATE OF BIRTH (NOTE: MONTH / DAY / YEAR)
DATE OF BIRTH (NOTE: MONTH / DAY / YEAR)
DATE OF CONSENT (NOTE: MONTH / DAY/ YEAR)
DATE OF CONSENT (NOTE: MONTH / DAY/ YEAR)
(1) I HAVE READ AND UNDERSTOOD THE INFORMATION SHEET ABOVE (VERSION 7, MAY 2016) (2) I HAVE HAD THE OPTION OF ASKING QUESTIONS BEFOREHAND. (3) I GIVE MY FULL CONSENT TO OSTEOPATHIC EXAMINATION AND TREATMENT. (4) I AM AWARE OF POTENTIAL SIDE EFFECTS AND IN PARTICULAR, 'CLAUSE 20'. (5) I AM LIABLE FOR FULL PAYMENT OF TREATMENT FEES FOR ANY CANCELLATIONS WITHIN 24 HOURS OF YOUR APPOINTMENT TIME, OR NO-SHOWS. *
* PLEASE TICK THIS BOX TO GIVE ELECTRONIC CONSENT.