CONSULTATION/ CONSENT TO TREATMENT

I confirm that I have had the relevant treatment explained to me and have received sufficient information about the treatment.

I have been given time to consider the treatment.

I have given the relevant medical history to the best of my knowledge.

I therefore consent to receiving treatment.

Full Name

Date of Birth

Address

Phone

If yes, please state

Your GP's name:

Your GP's contact number:

Please list all treatments you are having completed today:

Do you wish to provide any other information which feel may be relevant to your treatment?

Today's date

Signed

I declare that the information I have provided is accurate & complete

Thanks for submitting!