Registration and Consent - Charter Harley Street

1Client information

2Parents/Next of Kin/Significant Other - Emergency Contact

3Contact for Accounts/Finance

4Doctor/Counsellor/Psychiatrist/Specialist Details

5Consent

Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
Email*
Enter Email Confirm Email
Tel/Mobile*
Gender
Referred by/How you heard of Charter
Medication(s)

Name
First Last
Relationship to client
Address
Same as my address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Tel/Mobile
Email
Who will be making payment?*
- Myself
- Next of Kin/Parents
- Other

Name
First Last
Relationship to client
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Tel/Mobile
Email
*
By signing this form, I hereby give Charter Harley Street Ltd and its representatives permission to liaise with the above individual(s) regarding any outstanding invoice/payment ONLY:

By signing this form, I hereby give Charter Harley Street Ltd and its representatives permission to release/obtain confidential information about me relating to my medical history and treatment/s to/from any other professional services deemed appropriate.
*
DISCLAIMER: Please be aware in the event that a client is considered to be at risk of harm to himself/herself/themselves or others, Charter will contact next of kin/GP/specialist as and where appropriate.
*
By signing this form, I hereby give Mandy Saligari and the Referred Practitioner permission to release/obtain confidential information about me to each other only when relevant and where completely necessary.
Name*
First Last
Date*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.