Your Details
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Title
First Name
Last Name
Date of Birth
Name of Parent or Guardian (if under 16)
Home Address
Post Code
Mobile Tel
Email
As part of patient care, please indicate if you are happy for us to send written information to your GP, consultant and/or insurance company, and provide contact details.
Happy to send written info to
Private Health Insurance: If you have medical insurance and would like us to bill your provider directly, please provide your insurance details here. Please be aware that your insurance company may not pay the full amount of your invoice. Any remaining costs or delayed payments will be your responsibility.
Insurance Company
Membership No.
Authorisation No.
Your Consent
Please tick the following boxes to indicate you have read the information and understand what you are consenting to.
What information do we collect?
During your episode of care with Central Health Holdings you will be asked to provide a variety of personal information. Some will be personal identity identifying information (e.g. date of birth, email, home address, telephone number, Health insurance details). Under the GDPR, sensitive personal data is defined as: “data consisting of racial or ethnic origin, political opinions, religious or philosophical beliefs, or trade union membership, genetic data, biometric data, data concerning health or data concerning a natural person’s sex life or sexual orientation.” The only data under this definition CHH will collect is data concerning health. To support this medically confidential information, we will also ask some details about your personal history, which will not include the above, but may include: type of work undertaken, hours worked, job tasks, hobbies and exercise undertaken, among other relevant information.
Why do we collect this information?
Are there exceptions to this?
If there are safeguarding concerns or concerns of safety to yourself, our staff or members of the general public then Central Health have a legal duty to report our concerns to the relevant authorities without your prior consent. In the case of you going through any legal proceedings with regards to your injury (with external parties) or against Central Health, then Central Health’s legal responsibility to keep a record of your treatment undertaken with us will supersede any rights under GDPR.
Marketing Preferences
If you are happy for us to we send you monthly email bulletins containing news, blogs written by our specialist physiotherapists and special offers. Your details will not be passed onto any third parties. Tick the box to choose how we can contact you:
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