Patient Agreement Form - United Kingdom

This fillable "Patient Agreement Form" is a document issued by the United Kingdom National Health Service specifically for United Kingdom residents.

Download the PDF by clicking the link below and complete it directly in your browser or through the Adobe Desktop application.

ADVERTISEMENT
Patient Agreement Form
ase read through ALL the information below before signing. The surgery will
Ple
take a copy and will keep it in your personal records to show you agreed to the
practices terms and conditions.
Disclosure
I the patient agree to disclose all material facts regarding my health to my general practitioner and
other clinical staff.
Treatment of staff
I agree with the policy of zero tolerance of abuse towards all staff, also not to behave in an abusive,
threatening or otherwise aggressive manner with any member of the practice. I Acknowledge the
right of the practice to remove me from the surgery list without appeal should I behave in a manner
prohibited.
Repeat prescription
I agree to request any repeat prescriptions two full working days before collection and give three full
working days when a bank holiday arises. I understand I can only request prescriptions within the
surgery by filling out a form or online, I cannot request over the telephone.
Complaints
I understand that if I am dissatisfied with the services at Herschel Medical Centre, I must speak to a
senior member of staff or write my complaint in writing.
Confidentiality
Herschel medical centre declares that all matters and information pertaining to the patient shall not
be released without the patients consent.
Appointments and emergency appointments
I agree to attend on time for all appointments that I book with the practice and cancel any I cannot
attend in advance but contacting the surgery or personally information the member of staff at
reception. I acknowledge that if I arrive late for an appointment, I may be asked to rebook for
another time. I agree to only use emergency appointments for medical conditions that require
immediate treatment.
Home visits
I shall only request a home visit from the practice under circumstances where I cannot physically
attend the practice for an appointment.
Chaperones
I understand that a chaperone is available for any consultation at any stage and that I can request
this via the reception staff or any clinic staff.
Patient Agreement Form
ase read through ALL the information below before signing. The surgery will
Ple
take a copy and will keep it in your personal records to show you agreed to the
practices terms and conditions.
Disclosure
I the patient agree to disclose all material facts regarding my health to my general practitioner and
other clinical staff.
Treatment of staff
I agree with the policy of zero tolerance of abuse towards all staff, also not to behave in an abusive,
threatening or otherwise aggressive manner with any member of the practice. I Acknowledge the
right of the practice to remove me from the surgery list without appeal should I behave in a manner
prohibited.
Repeat prescription
I agree to request any repeat prescriptions two full working days before collection and give three full
working days when a bank holiday arises. I understand I can only request prescriptions within the
surgery by filling out a form or online, I cannot request over the telephone.
Complaints
I understand that if I am dissatisfied with the services at Herschel Medical Centre, I must speak to a
senior member of staff or write my complaint in writing.
Confidentiality
Herschel medical centre declares that all matters and information pertaining to the patient shall not
be released without the patients consent.
Appointments and emergency appointments
I agree to attend on time for all appointments that I book with the practice and cancel any I cannot
attend in advance but contacting the surgery or personally information the member of staff at
reception. I acknowledge that if I arrive late for an appointment, I may be asked to rebook for
another time. I agree to only use emergency appointments for medical conditions that require
immediate treatment.
Home visits
I shall only request a home visit from the practice under circumstances where I cannot physically
attend the practice for an appointment.
Chaperones
I understand that a chaperone is available for any consultation at any stage and that I can request
this via the reception staff or any clinic staff.
Mobile phones
I agree to either switch my phone off or ensure it remains on silent at all times whilst being within
the practice. When making and receiving phone calls I must stand outside that practice to respect
other patients around.
Policy on seeing minors
I understand that all children up to the age of 16 must be accompanied by an adult to see any clinical
staff member. I understand that the confidentiality policy gives any patient over the age of 16 to
retain any of their test results and can be given to the parent only if permission is clearly stated by
the patient in their records or a staff member has received verbal consent from the patient.
Private Fees
I understand and accept that the surgery is asked to write letters and complete forms on behalf of a
patient, which is not covered under the NHS. I agree that in such circumstances, there will be a
charge, which may vary depending on type of request made. Please contact the surgery or speak to a
member of staff at reception for details of our fees, before leaving your request. I understand that in
most cases, a doctor’s appointment is not necessary when the completion of a form is needed. I
agree with the surgeries policy, that I must leave the form with a member of staff at reception along
with the correct payment before completion and that the surgery cannot provide any further
change. I understand that I must allow at least 7-10 working days before the successful completion
of a form.
Please state your full name _________________________________________________
Signature___________________________________________ Date_____/_____/_____

Download Patient Agreement Form - United Kingdom

333 times
Rate
4.5(4.5 / 5) 17 votes
ADVERTISEMENT
Page of 2