By sending this form, 

* I agree that I am responsible for the payment of all fees to Dr Lip Teh for consultation, surgery or any reports requested  on my behalf for medicolegal reasons.

* I acknowledge that I have read and understand the information provided in the practice’s Privacy Policy (available in hard copy upon request). I provide consent for this practice to collect, use and disclose my information as outlined in the policy.

**if provided, your mobile number will be used as your main contact number and for text message appointment reminders (unless you advise us otherwise)