Registration Form

PLEASE COMPLETE THIS FORM IN FULL AND CLICK ‘SUBMIT’ SO THAT WE CAN REGISTER YOU WITH OUR PRACTICE. PLEASE REVIEW OUR GDPR INFORMATION DISCLOSURE | POLICIES & PROCEDURES FORM HERE.

Name

First Name

Last Name

Home Address

Mobile Phone

Date of Birth

Please indicate your insurance provider (if applicable)

Please provide your insurance policy number & authorisation code (If applicable)

Cancellation & Rescheduling Policy

We operate a standard 48 hour cancellation/rescheduling policy. As such, if you need to cancel or reschedule please do provide us with a minimum of 48 hours notice. Payment will be required for sessions that are cancelled, rescheduled or missed with less than 48 hours notice.

I have read, understood and agree to your 48 hours cancellation/rescheduling policy

Consent to Treatment & GDPR Procedures

Please click on the link at the top or bottom of this page or go to the following link to read about our policies as well as our GDPR data protection procedures - www.drsiriharrison.com/policies-procedures-gdpr

I have read your policies and procedures and consent to treatment with HPG

I have read and understand your GDPR policy

Emergency Contact (Name & Phone)

Please note that we fully maintain your confidentiality according to legal and ethical standards. Your emergency person would only be contacted in the event of a true emergency.

Please provide a brief description as to why you're seeking psychological support?

PLEASE REVIEW OUR GDPR INFORMATION DISCLOSURE | POLICIES & PROCEDURES FORM HERE.

Registration Form

Dr Siri Harrison

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