Consent to Treatment and Sharing Information

Full Name

Phone *

Date of birth *

Email *

I understand that:

I am agreeing to have treatment or support from [Clinic/Service Name].
I have been told why the treatment is needed and how it may help.
I can ask questions about the treatment at any time.
I can stop the treatment at any time — this won’t change my future care.
I understand any possible side effects or risks.

👉 Select the box if you agree to treatment

I understand that:

Some information about me may need to be shared with people who are helping with my care.
My information will only be shared to help with my care.
My information will be kept safe and private.
I can change my mind at any time by telling someone.

👉 Select the box if you agree to Share Information *

👉 Tick the box if you give Consent to Share:

👉 Tick the box on How to Communicate with Me

Other Information

By signing this form, I agree that I understand and accept what is written here.

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By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.