Patient Informed Consent Form

Patient Informed Consent Form

Please read carefully, complete, e-sign and submit this form at least 7 days prior to your first visit to a Health Optimising UK Clinic. Please note we will only be able to register and see you after we receive your completed form which covers this and subsequent assessments, tests or treatments.
Patient Full Name

First Name Last Name
Parent/ Guardian Full Name (if different)

First Name Last Name
Email
example@example.com
Mobile Phone Number
Patient Date of Birth

Month Day Year
Date
I give permission for Health Optimising UK to carry out an assessment and/or treatment and have read and understood the relevant Treatment Information Guide or information on the website and Pre-Appointment Preparation Guidance about the process and any associated risks or contraindications. I understand that it is my responsibility to ask any questions that I might have by email and the clinic will answer them.

I agree that it is my responsibility to inform the clinic /clinician of my current health status, vaccination status, all current medications, and therapies and to keep the clinician aware of changes in these for every session.

I agree that it is my responsibility to complete my Health Optimising Questionnaire/ Natural Fertility Questionnaire at least 7 days prior to my appointment and provide you with full information about my health including but not only past traumatic injury, disability, heart condition/ stroke, diabetes, lung conditions, regular medication, asthma, and allergies.

I understand that, as the health consequences of the COVID vaccination are not yet fully understood, I cannot hold Health Optimising UK liable for any unsatisfactory results, short-term illness, long-term illness, or more serious consequences resulting from the impact of the COVID vaccination on my health.

I have read and understood your Terms and Conditions, Legal Disclaimer, and Data Privacy Policy found here:

T and C's and Disclaimer

Data Privacy

Legal Medical Disclaimer

Information and statements made on our website and all our associated literature are for educational purposes only and are not intended to diagnose, treat, cure or prevent any disease. The practitioners of Health Optimising UK do not dispense medical advice, prescribe restricted medicines, or diagnose disease. If you have a medical condition, we recommend that you consult your physician of choice.

Patient declaration:

I have answered, understood, and given Informed Consent to the best of my knowledge to authorise the assessment/ treatment. I confirm that I have understood the treatment that I am about to receive and confirm that I am willing to proceed without confirmation from my own GP or consultant. I certify that all the information provided is correct.
Signature

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