Patient Registration


Date of Birth:





Private Health Insurance

YesNo


I understand that it is my responsibility to ensure that any medical insurance policy I might ever use covers me for Osteopathic treatment and that if for any reason my insurer refuses to meet all or part of the fees due to Lisa A Gibbs & Associates (such as policy excess fees or restrictions on the number of treatments allowed under the policy) then I will settle those costs directly with Lisa A Gibbs & Associates.

I understand that payment for my treatment is due on my appointment date (we accept cash, credit/debit card, & cheque), and that if I ever wish to claim for my treatment under a private health insurance policy or via any third party then it is my responsibility to ensure that the treatment fees will be met and that if for any reason my insurer or any third party refuses to meet all or part of the fees due to Lisa A Gibbs & Associates then I will settle those costs directly with Lisa A Gibbs & Associates.

Consent to Handle Data

Under 1616 to 18Over 18

I explicitly consent to you creating and storing medical records concerning the treatment of my child. I understand that this may include details concerning medication, treatment and other issues affecting health conditions, in accordance with the General Data Protection Regulation (GDPR). I understand that these records will be retained until the child reaches 25 in order to comply with the Institute of Osteopathy legal guidelines. I understand that these records will be processed in accordance with your 2018 Privacy Notice, a copy of which I have seen.
2018 Download Privacy Notice

I explicitly consent to you creating and storing medical records concerning my treatment, which may include details concerning my medication, treatment and other issues affecting my health conditions, in accordance with the General Data Protection Regulation (GDPR). I understand that these records will be retained until I reach 25 in order to comply with the Institute of Osteopathy legal guidelines. I understand that these records will be processed in accordance with your 2018 Privacy Notice, a copy of which I have seen.
2018 Download Privacy Notice
I explicitly consent to you creating and storing medical records concerning my treatment, which may include details concerning my medication, treatment and other issues affecting my health conditions, in accordance with the General Data Protection Regulation (GDPR). I understand that these records will be retained for eight years from when treatment is ceased in order to comply with the Institute of Osteopathy legal guidelines. I understand that these records will be processed in accordance with your 2018 Privacy Notice, a copy of which I have seen.
2018 Download Privacy Notice

Contact

For future appointments and administration Lisa A Gibbs & Associates may need to contact you by phone, email, and/or post.

Additionally, if you are happy for us to contact you with our own information, promotions, and offers please tick this box:

Lisa A Gibbs & Associates will never share your private data for marketing purposes with any third parties.

If you don’t yet have an appointment and would like us to call you to arrange one please tick this box:

Cancellation Policy

Missed appointments will incur a 50%* cancellation fee if less than 24hrs notice is given.
*100% for appointments at the weekend, before 9.30am, or after 5.00pm.
We apologise that this policy has become necessary.