Tinnitus and hyperacusis therapy specialist unit

Patient Intake Form

Date of completing the form

Name of the patient

Date of birth

Gender

Current medications

GP name and address

GP phone number

With whom do you live?

Your home address

Your email address

Your phone and mobile numbers

Your emergency contact /next of kin phone number

I agree with the statement below:
I understand that my assessment and treatment reports developed by Hashir International Institute may be shared with my GP and/or other health care professionals directly involved in my care (if needed). I understand that sharing patient’s reports with other health care professionals involved in their care is a part of routine practice in medicine and healthcare science. I understand that all of the information discussed in my sessions will be treated as confidential. Confidentiality will be broken if there is a risk that I may hurt myself or others. I understand that unidentifiable (anonymised) data related to my care (or my child’s care in the case of paediatric clinic) at Hashir International Institute may be used for evaluation of their services, training, research and development (R&D), and publications. No identifiable information will be published. I understand that Hashir International Institute is a UK-based organisation. Therefore, my involvement with Hashir International Institute as a patient (or parent/legal guardian of a patient) shall be governed by English Law and the English Courts shall have exclusive jurisdiction to deal with any dispute which may arise out of or in connection with my (or my child’s) treatment.