New Patient Enquiry

Consent Form

"*" indicates required fields

This form authorises 5D Clinics representatives to legally request and receive your medical information from third party providers, including but not limited to, Medical imaging reports, Biopsy reports, Histopathology, pathology reports, medical letters and previous radiotherapy treatment details.

Patient name*

Patient date of birth*

Address*

Email*

Phone*

Please attach links to results if available or list pathology and/or imaging centres that you attended for relevant tests

By signing the below, you agree to the content and conditions outlined in the Consent Form.

Patient Full Name*

Date*

Signature