Welcome to Phoenix Medical Clinic in Watford.

I would like Phoenix Medical Clinic to examine my child under its private medical treatment scheme and to give me any necessary care and treatment that I am willing to undergo with Phoenix Medical Clinic arrangements.
I declare I that I agree to pay the Clinic’s fees in relation to the treatment received.
I declare that any information given on this sheet is correct and complete.
I agree that some data processing will take place and my personal data will be kept safely in the Clinic’s database.

AUTHORISATION TO RELEASE NON-PUBLIC PERSONALINFORMATION
I hereby authorize Phoenix Medical Clinic or a dentist/doctor at the clinic individually, to release any of my or my dependent's medical, dental or incidental non-public personal information that may be necessary for medical/dental evaluation, treatment, consultation or the processing of insurance benefits.

AUTHORIZATION TO E-MAIL, CALL OR TEXT
I certify, that I understand the privacy risks of e-mail, phone calls and text messaging. I hereby authorize Phoenix Medical Clinic representative, doctor or dentist to e-mail, call or text myself with communications regarding my health, including but not limited to things such as appointment reminders, referral arrangements and follow up care. I understand that I have the right to withdraw this authorization at any time my notifying Phoenix Medical Clinic to that effect in writing.

CONSENT TO TREATMENT:
I Hereby consent to evaluation, examination and treatment as directed by Phoenix Medical Clinic or his or her designee.

NON-CANCELATION CHARGE; CLINICAL PROCEDURE ACCEPTANCE
I hereby confirm I understand and accept that in case I book an appointment with doctor/dentist at the clinic and if I'm not able to make the appointment I need to contact the clinic in order to cancel/postpone it no longer than 24hours prior to the appointment, Failing to do so may results in the clinic charging me a Non-Cancelation fee of £50.