Patient Data & Consent

Patient Data & Consent

Upon submission of your patient data and consent, the information you provide below is encrypted and stored on secure servers in full accordance with Dr Naomi Whitelaw’s (trading as Equilibrium) Privacy, Confidentiality, Information Governance and Data Protection Policies. Copies of these can be provided upon request.

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Title
Name
We will not contact your doctor without your consent unless in the event of a medical emergency.
Disabilities, Pre-existing Conditions or Illnesses
Private Insurance Details (are you claiming for all or any aspect of your treatment?)
Please note that it is your responsibility to check the terms and requirements of your policy, as the treatment we offer may not be covered.
Contact concerning your treatment may be necessary. This might be to rearrange an appointment, book a review, enquire about medication or a treatment-related matter.
THIS IS NOT MARKETING CONTACT BUT PURELY TREATMENT-RELATED COMMUNICATION.
If you are prescribed medication, Equilibrium Clinic's designated pharmacy may wish to contact you regarding your prescription.
The pharmacy will normally take a telephone contact number and email address from you when you call for your medication.
Treatment Associates. This refers to practitioners or your GP and/or specialists who work alongside us (with your prior agreement only) in the delivery of treatment (e.g. Diet & Nutrition, Scans, Vitamin Therapy etc.)
This relates to third parties whose treatment you have agreed to. Referrals to third parties are not made without your prior agreement, which is a decision reached between you and the doctor.
Laboratories & Diagnostic Partners. If blood or other samples are required it is usually mandatory to provide patient information such as name, gender and date of birth and for sample queries or tracking purposes often contact details too.
Why is this necessary? For diagnostics to be undertaken it is vital that samples are matched to the correct patient and that patient data such as gender and date of birth are correct.
Photo ID is required in line with our compliance needs
Please email a copy to support@equilibrium-clinic.co.uk ahead of your appointment.
Email Appointment Reminders (please see notes below)
We always send appointment reminders by email, as often other information is included. Please indicate if this is NOT a reliable way to remind you.
Location for Video Consultations
Your location is required as part of our safeguarding policy.
You need only complete this if you will attend your video appointment from your work address. Your location is required as part of our safeguarding policy.
Do you have any known allergies?
Are you currently following a 'paid for' diet or supplementation plan?
For example shakes and/or special meals (we do not mean regular over the counter products such as multivitamins).
Name of emergency 'Next of Kin' contact
Emergency contact
Please confirm you are happy for us to contact your next of kin in the event of an emergency
Chaperone Requirements
Please complete the box below if you intend to have a chaperone some or all of the time.
Please let us have your chaperone's name and relationship to you, plus any other information you feel pertinent.
Marketing Preference
Our marketing activity is minimal and will only relate to the introduction of new services, products and/or clinic locations etc. We do not share information with any third parties without prior consent.