To register at our practice and access our services please complete this registration form. The information you provide will be encrypted and sent to our reception team.
If you are a parent and registering your child to receive services from the practice, you will need to complete this form as the (Bill Payer) for yourself and a registration form for your child (Client).
The individual completing the form should provide their details here. For those registering a child or young person their details should be provided further below.
Children and Young Persons
Clients registering children or young persons should provide their childs or young person's details below.
We will not contact your GP, or anyone else for that matter without your prior consent, unless during the course of any therapy or assessment a concern is raised for your immediate welfare. To find out more about our confidentiality agreement please read our terms and conditions.
Adults registering children, please provide the child or young person’s GP
In case of emergency
Hopefully we will never need to use this but in case of an emergency please provide the contact details for at least one other person.
Security and Email
Consent to share
If you would like us to speak to a nominated person on your behalf regarding your treatment and/or you consent for us to send confidential information regarding your services to a third party, please complete the following section.
If you would like to register additional persons please use our standard discloure form which can be found on our website.
Please indicate how you would prefer us to contact you
We kindly ask that you ensure the information provided on this form is accurate. Please ensure you are happy with them, particulary our cancellation policy and then tick the box below and sign the form using your finger, sylus or mouse.
By registering with The Practice MK you are agreeing to our terms and conditions and at all times be responsible for your fees. If you are registering a child (under 18) you agree to be responsible for their fees.
If you have a medical insurance policy or if a third party has agreed to pay for part or all of your fees, you will be required to complete a Third-Party Fees Declaration Form, available on our website providing us with consent to contact them.
Our full terms and conditions would have been sent to you in an email or they can be assessed at the bottom of this form.