New Patient Registration Form

5 Minutes to complete

We take your privacy very seriously. We collect, use and are responsible for certain personal information about you. When we do so we are subject to the General Data Protection Regulation (GDPR).

Our Privacy Policy is available on our website thekarriclinic.co.uk/privacy-policy/ or from our reception and contains important information on who we are and how and why we collect, store, use and share your personal information.

Date of Birth(Required)
Name(Required)
Address(Required)

If you have provided an email address, your preferred method of contact will be automatically selected as email.

Surgery Address

Your Consultation

During your consultation with Mr Karri, a physical examination will likely be required. Your examination will always be handled with the utmost respect and consideration for your dignity. You are welcome to have a chaperone present during the consultation / examination.

Medical Photography Consent

During your consultation(s), Mr Karri may take clinical photographs or video recording of your body part, which are stored as part of your health record. These clinical photographs or videos will only be used for the diagnosis and monitoring of your medical condition(s) and will be stored in a secure database.

You do not have to agree to a photograph or video being taken. However, in some cases, refusal may stop Mr Karri from achieving the best possible outcome for you.

Your photos and/or video may be used for other purposes. Your identity will NEVER be revealed without your explicit written consent.
Please tick if you consent for your clinical photographs/video to be used for;
Please tell us about any illnesses/ conditions you are being treated for:

Do you take any of the following medicines?

Are you diabetic?(Required)
Anti-depressants(Required)
Anticoagulants (e.g. warfarin, aspirin)(Required)
Immunosuppressive medication(Required)
Do you smoke?(Required)



DD slash MM slash YYYY
This field is for validation purposes and should be left unchanged.