Patient Registration and Consent Form Please complete our registration form to begin your treatment journey. Personal Details Name * First Name Last Name Date of Birth * MM DD YYYY Address * Phone * (###) ### #### Email * Gender * Male Female Other/Prefer not to say GP Practice Name and Address * Medical History Do you have any existing medical conditions? (e.g., diabetes, heart disease, high blood pressure) * Yes No Are you currently taking any regular medication? (including any over the counter or herbal medication) * Yes No Do You have any allergies? (e.g., medications, food, latex) * Yes No Have you experienced any adverse reactions (side effects) to medications before? * Yes No Do you smoke? * Yes No Do you drink alcohol? * Yes No Treatment & Consent I confirm that the information provided is accurate and complete to the best of my knowledge. * I Confirm I consent to receiving private medical treatment from MNJ Medical Ltd. * I Consent I understand that this service is private and not covered by the NHS. * I understand I agree to follow any prescribed treatment plan and notify my prescriber of any changes in my medical condition. * I agree It is important to notify your GP when receiving private treatment to ensure safety and continuity of care. Do you want MNJ Medical Ltd to notify your GP? * Yes, notify my GP always. Notify my GP only when clinically necessary. No, do not notify my GP. I acknowledge that it is my responsibility to inform my GP and any other healthcare providers about the treatments I receive privately. Data Protection & Privacy Notice Data privacy and security * MNJ Medical Ltd is committed to protecting your privacy and ensuring the security of your personal data in line with the General Data Protection Regulation (GDPR). By signing this form, you consent to the collection, processing, and secure storage of your information for the purpose of providing medical care. Your data will only be used for medical purposes and shared with healthcare professionals when necessary. Your information will not be shared with third parties without your consent, unless required by law. You have the right to access, amend, or request the deletion of your data at any time. For more information, please refer to our Privacy Policy or contact us at niral.joshi@mnjmedical.co.uk. I have read and understood the Privacy Policy. By submitting this form you also agree to our terms of service. Thank you! Your submission will be reviewed and we will be in touch.
