New Patients Form

Dear Patient,

To comply with the Government’s new Privacy Legislation, we are required to gain your consent to enable us to handle personal information about you.

Please read our Privacy Policy carefully, to ensure that you agree with the manner in which we will be handling your personal information. If you are unsure about anything in either our Privacy Policy or this letter, then please ask us for clarification. Once you have read this information, please enter your name, date of birth and address on the bottom of this form and then sign it.

“I have read Canterbury Medical Clinic’s Privacy Policy and I Understand the reasons why my information must be collected. I understand that I am not obliged to provide any information requested to me, but that my failure to do so might compromise the quality of the health care and treatment given to me. I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances. I understand that if my information is to be used for any other purpose other than set out above, my consent will be obtained. I consent to the handling of my information by Canterbury Medical Clinic for the purposes set out in the Privacy Policy handed to me today, subject to any limitations on access or disclosure that I notify this practice of.”