NEW CLIENT FORM

Note additional charges apply, please chat to one of our team members for full T&C's.

Please note we are only able to discuss patients medical information with the primary and secondary contact person listed on this form. If there are any other persons that you wish for QVCC to communicate personal information with, please list:

By signing this form, I/We agree that…
i. All questions by us have been answered satisfactorily;
ii. I/We have read and understood this document;
iii. Authorise and consent is given as required;
iv. Agree to QVCC’s payment terms and conditions;
v. Aware that all payments are due at the time of service;
vi. Agree to be personally responsible for all professional fees as rendered by QVCC;
vii. Aware that whilst all care is taken by QVCC, I/We have had the risks explained and hereby indemnify and keep indemnified QVCC and employees against claims howsoever arising.