Name *
Please enter your full address along with postal code
If different from home address
Contact full name *
Contact full name
GP's Name
GP's Name
We would use your email/ phone numbers to get in touch with you regarding your current and future appointments.
Services *
We would like to let you know about our latest offers, promotions and service. Please tick the methods you are happy for us to contact you with.
Occasions *
We would like to send you vouchers and greeting cards on special occasions. ( Eg: Your birthday, Christmas)
Terms *
Your data will be stored in secure servers in accordance with General Data Protection Regulation 2018. Any changes in the security settings of your data will be notified to you promptly. If at any time you wish to stop receiving communications from us, you can inform us to change your preferences. I have the right to erasure (right to be forgotten) of my personal data. I understand that I can request my personal data at any time. I understand the Living Mind may have to share my details, with my GP, other relevant healthcare professionals, relevant pathology services and my insurance providers on a need to know basis as and when appropriate. I understand that administrative officers and clinicians at Living Mind will have access to relevant data for specific purposes. E g: creating reports, invoicing, appointment management, liaising with healthcare professionals, and relevant pathology services. I understand that I can withdraw consent for treatment at any time.
If you would like to know how we are storing your information please take a look at our recently updated PRIVACY POLICY at the end of this page.
Treatment *
The doctor or therapist has fully explained the treatment procedure and I give consent for the treatment.
Print full name as form of digital signature
This will be added to your digital signature