Patient registration form

You can complete this form online prior to coming to your appointment.  Don't forget to tell our receptionist that you have done this, so you don't need to complete another registration form.
Your information is confidential and will be received directly by South East Colorectal.
Your privacy is important to us and your information will not be shared with any third party without your permission.

    DETAILS
    South East Colorectal collects the above information on you for the primary purpose of providing quality health care, including an accurate patient record. This information is used for administrative purposes, disclosure to others involved in your health care, for referral on to other doctors and specialists, for hospital admissions, or for medical tests. Our practice has a privacy policy on the handling of patient information and South East Colorectal upholds the highest standards of patient confidentiality.

    Our practice is also a teaching facility, therefore students may sometimes be in attendance during your consultation. Please advise reception if you do not wish to have a student present during your consultation.

    I understand that there will be costs involved in my consultation and that payment of my account is due on the day of my consultation.  I confirm that I have read and understood the above and by clicking SUBMIT I give my consent to South East Colorectal to use my information as outlined above.