ONLY FILL IN IF DIFFERENT TO PATIENT DETAILS
I give permission for photographic medical images to be stored in my medical records to aid my clinical treatment. These images will not be used for commercial purposes. I understand any information supplied is confidential and my privacy is always maintained.
I declare that all information given on the above form is true to the best of my knowledge. I understand that in the event that a procedure is required to be booked at Oxford Day Surgery this form with be provided to their rooms for booking and medical purposes.