Witamy w Phoenix Medical Clinic, Watford.

I will answer all health question on the Medical History Form to the best of my knowledge.
After assessing my health issue by the doctor and accepting proposed treatment, I hereby authorize the performance of dental/medical services upon the above named patients and whatever procedures that the judgment of the doctor may decide in order to carry out these procedures. I also authorize and request the administration of any anaesthetic and/or x-ray as may be deemed necessary and advisable by the doctor.

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.