New Patient Registration Form

Please complete the new patient registration form below:

New Patient Registration
Please enter without spaces.
Please enter without spaces.
How did you hear about the practice?

Data Consent:


We collect certain data from you to meet mandatory requirements regarding medical notes. there is a legal requirement to keep medical notes for a period of time after treatment This can vary in length depending on your age and ability to consent but will be for a minimum of 7 years. Your details will be destroyed after this period.
Please note if you do not consent by ticking the boxes below, we will be unable to carry out any assessment or treatment.
We collect certain data from you to meet mandatory requirements regarding medical notes. there is a legal requirement to keep medical notes for a period of time after treatment This can vary in length depending on your age and ability to consent but will be for a minimum of 7 years. Your details will be destroyed after this period. *
There may be occasions where we may want to share information with your general practitioner.
There may be occasions where we may want to share information with your general practitioner. *
We also collect data to assist in the administration of our business to provide you with an efficient service. We would like to use your contact details to assist with the administration of your appointments/changes to scheduled appointments and/or reminders about appointments. To further enhance our service to you, we would like to be able to update you on any information regarding the practice.
We also collect data to assist in the administration of our business to provide you with an efficient service. We would like to use your contact details to assist with the administration of your appointments/changes to scheduled appointments and/or reminders about appointments. To further enhance our service to you, we would like to be able to update you on any information regarding the practice. *
We take your privacy seriously and will take all reasonable steps to ensure the protection of your data. Please note that your right to be forgotten cannot override the legal requirement to keep medical notes for the mandatory period. You can request a copy of any data held on you using the details at the bottom of this form.
By typing your name in the box above this will act as your digital signature.
DD/MM/YYYY

Practice Details

This is who your details are held by

Emma V. Westers
Centre4Feet, 1 Ray Lane, Blindley Heath, Surrey, RH7 6LH.
Tel: 01342 834454

Please ensure you complete the Medical History Form if you have not already done so.