HSH Outpatient Room Booking Form

HSH Outpatient Clinic Room Booking Form

1) This form should be used to book for a consultation room, Please use HSH "Minor procedure Booking Form" for any minor procedures.
2) Use of Medicines at the HSH: Please note that some injectable such as Botox, Hyaluronic acid and steroids require patient prescription which needs to be supplied by the HSH pharmacy in order to comply with CQC regulations. No practitioners/clinicians are allowed to supply external medications to treat patients at the HSH.
3) Only CQC registered clinics can handle and manage their own medications if their licence covers this activity. Please inform HSH Pharmacy ASAP if you are planning to store, handle or undertake any treatments involving medicines at HSH.
4) All practitioners should have Practising Privileges before seeing any patient at the HSH.
HSH requires all patients and practitioners attending the hospital:
-must be asymptomatic
-not being advised to self-isolate by the NHS track and trace
-to wear a face mask before entering the hospital
-For Clinicians/Practitioners: negative COVID19 antigen testing performed regularly (minimum once a week)
Please tick to confirm that*
- You understand the above and agree to comply with the policy
Date Completing Form
Date Format: DD dash MM dash YYYY
Clinic Information
Name of the Clinician/Practitioner booking the room*
What is the room booked for?*
Date to book room
Date Format: DD dash MM dash YYYY
Time From
: HH
MM
How long do you require the room for?
Please Specify*
Patient Information
How would you like to submit the clinic list*

List*

Appt. Time	Patient Name	DOB	Phone no.	Email

Clinic Patient List
Here you are able to copy-paste clinic lists already existent elsewhere into this box. Please ensure that the Appt. Time, Patient Name, DOB, Email and Ph no. is included in each line.
Will any patients require a chaperone? If so, tick
- Yes
Please specify which patients require a chaperone
Confirmation
By using this form, please tick*
- I agree with Hospital Terms and Conditions
By using this form, please tick*
- I agree with the HSH Privacy Policy
Name of person completing form who has the authority to make this booking*
Email*
Signature*

HSH Outpatient Clinic Room Booking Form

Clinic Information

Patient Information

Confirmation

Are you ready for a consultation?

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