Records Update Questionnaire

Podcasts

RECORDS UPDATE QUESTIONNAIRE

Please Note: If you do not wish to complete the questionnaire online please contact the surgery and we will arrange a paper copy to be sent to you.

* Required Field

RECORDS UPDATE QUESTIONNAIRE

Patient Details

*Firstname:
( 1st 3 Chars)

*Surname:
(1st 3 Chars)

*Date of Birth:
(DD/MM/YYYY)

/ /

General Medical Details

*What is your
Smoking Status?

	Smoker
	Ex-Smoker
	Never-Smoked

*What is your Height?

Metres:		Cm:
Feet:		In:

*What is your Weight?

Kilogrammes:
Stones:		Lb:

Blood Pressure.
If you monitor your blood pressure at home, what was your last recording ?

over

Contact Details

Home Telephone Number:

Mobile Telephone Number:

*E-Mail Address:
(your-email@address.com)

CONFIDENTIALITY - TERMS AND CONDITIONS:
This is to confirm that I wish to register for the Waterside Medical Centre online appointment booking system.

The internet is not secure, and the transmission of data to request medication is entirely at the patient's own risk. The practice accepts no responsibility for breaches in confidentiality resulting from patients' transmissions.

I accept the terms and conditions above

Hald Chiropractic Clinic

Philip Plant - Chiropodist

Nicola Bryan-Harris: Chiropodist/Podiatrist

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