Patient Registration (Allergy) Please complete this registration form if you are a new patient, or have not attended the clinic for 12 months or if your details may have changed Name * First Name Last Name Email * Title Miss Ms Mrs Master Mr Sir Honourable Lady Dr Phone Country (###) ### #### Gender Male Female Prefer not to say Address Address 1 Address 2 City State/Province Zip/Postal Code Country Patient's Date of Birth D/M/YYYY Please provide details for you/your child's next-of-kin Please let us know if you/your child have any special needs or accessibility requirements If someone other than a parent of the child will be taking them to their appointment, please state their details below They will be required to provide identification matching this name at the front desk upon arrival. Consent * I confirm that, to the best of my knowledge and belief, the information I have given on this form is true and correct. I consent to all relevant medical records and images being stored digitally by ent4kids until I notify you otherwise. I hereby undertake to pay ent4kids for services & materials relating to my/my child's treatment as a private patient, including any circumstances where medical insurance proves not to cover the specific course of treatment, in which case I agree to settle my account upon receipt of invoice. I consent to my details being shared with a debt collection agency should I fail to settle the account within the payment terms. Should it be necessary to refer to a third party medical provider for a further opinion/further diagnostic testing, I consent to the sharing of my personal data to facilitate this referral. Should your medical insurance company require a diagnosis, or medical report for payment purposes, I consent to the sharing of my personal data to facilitate this claim. I Consent Thank you!
