Personal Data Confidentiality Agreement - Free Download
4.8, 2920 votes
Please vote for this template if it helps you.
Personal Data Confidentiality Agreement
Personal Data Confidentiality Agreement
Confidentiality Agreement and Personal Data
Your personal information:
By attending Cleveland Clinic (2008) Ltd (hereafter the ‘Practice’) as a Registered Patient, any information given to us will be
used by for the purposes of healthcare and related services and administration.
Personal data relating to you will be retained by the Practice for the purposes of providing you with medical and healthcare
related services both in the Practice and where appropriate at the premises of other healthcare providers. This may require
your personal data including relevant details of your medical history to be shared with other healthcare providers for the
purpose of referrals and for other lawful purposes related to the Practice procedures.
Your declaration to us:
I understand that the Practice has the right to accept or decline my registration at any time.
I understand that by attending a consultation with a GP or other healthcare professional of the Practice I accept the
Practice terms of service and fee schedule issued and displayed in the Practice premises and as amended from time to
I hereby agree to pay for all treatment given by the Practice or other healthcare professional of the Practice at the
time of the treatment. I expressly consent that prior to accepting any credit arrangement from the Practice, where
appropriate a credit reference check may be taken with an authorised credit reference agency and/or my previous
medical Practice(s).
I give my express permission for the Practice to request information including my medical records from my previously
registered GP and I agree to reimburse the Practice for all charges and disbursements relating thereto for being
provided with such information.
I confirm that all the information I have given at the time of registration is accurate to the best of my knowledge.
Furthermore I understand it is my responsibility to advise the Practice in writing of any changes made in respect of my
personal information.
Practice Terms of Service and Fee Schedule
Patients are encouraged to pay for all consultations on the day of being seen. If they do not pay on the day, they will be sent a statement
of account, with an administration charge of £5 added. All payments must be made within 30 days from the date of the statement.
Another administration charge of £5 will be added if the statement is re-sent. We reserve the right not to offer on-going medical
services for clients with outstanding accounts.
New patients who have not been with us for 12 months and those visiting the Practice will be expected to pay for all treatments the
same day. If they do not, they will be sent one reminder in the post, together with a bill for £5 to cover our administration costs.
Payment must be made in full within 7 days from the date of the statement. If we do not have a response from the letter within 7 days
of receipt, they will be sent to a debt collecting agency and may be removed from the Practice register. This will mean that they will not
be given any further appointments and the out-of-hours Doctors will be told that they have left the Practice.
Please remember, if you have any difficulties in paying for treatment, we would rather you speak to us. Please ring our Accounts
Department between 9am and 12.30pm on 01534 713694.
All fees are subject to change- updated October 2014Please note all marked extras are charged on top of a consultation fee
Antenatal Care Package
Consultation (under 5’s)
Cervical Smear (extra)
Home Visit ( 8am 6pm Mon-Fri )
Ear Syringe (extra)
Repeat Prescription
£2.00 per month supply (£6 per script if posted)
ECG (extra)
Blood Test
£12.00 (extra)
Vaccines (extra)
Please ask Reception for a complete list if required
Personal Data Confidentiality Agreement Previous Page
Personal Data Confidentiality Agreement