Digital Consent Form

First Name *

Last Name *

Phone *

Email *

Please use the same email address you provided at the time of booking. Using a different email may result in being asked to complete the consent form again.

Date of birth *

Address

Street Address *

City

State

Country

Postal code

Do you suffer from any condition that causes balance problems or vertigo attacks? *

Yes

No

Have you suffered from any pain in your ears within the last 30 days? *

Yes

No

Do you have a perforated ear drum? *

Yes

No

Are you currently under ENT consultant or receiving any treatment regarding your ears? *

Yes

No

Are you currently using any anti-coagulants? E.g. Warfarin *

Yes

No

Are you currently suffering from hearing loss? *

Yes

No

I'd like to keep up date with the latest discount offers and marketing content via:

Phone

Email

Post

GDPR Agreement *

I consent to this clinic using the information I have provided to offer me the most suitable level of care.

By signing and submitting this consent form, you are agreeing to our company Terms and Conditions, you accept that you have read and understand the possible complications that may occur and agree that Park Medical Clinic or any of its employees, cannot be held responsible for these. I declare that I have read and understood these terms and conditions and am willing to be bound by them.

Signature:

Clear