Patient Acknowledgement form

Patient Acknowledgement — independent practitioner

To be signed by every patient (or their legal representative) on arrival, before any examination or treatment.

Your dentist / clinician today:GDC number:

Please read and sign:

1. I understand that the clinician named above is an independent practitioner who is renting a room at 341 Birmingham Road, Great Barr, Birmingham B43 7AP.
2. I understand that they are not part of, employed by, or connected with The Dentist West Midlands, Dhodys Ltd or Management FD Limited.
3. I understand that my treatment, fees, records, aftercare and any complaint are entirely between me and the clinician named above.
4. I understand that The Dentist West Midlands, Dhodys Ltd and Management FD Limited are not responsible or liable for my treatment or care.
5. I have been given the clinician's own contact details for appointments, aftercare and complaints.

Patient name:Date of birth:

Signature:Date:

If signed by a representative — name:Relationship:

The clinician keeps this form with the patient's record and gives a copy to the building owner on request.