Privacy Notice Acknowledgment template

1. What Information Is Collected

• The Provider collects personal and, where relevant, health information necessary to deliver services, including contact details, session notes, and billing information.

2. How Information Is Used

• Information is used to provide and coordinate services, manage appointments and billing, and comply with legal and professional obligations. It is not sold to third parties.

3. Legal Basis and Retention

• Information is processed under the UK GDPR and Data Protection Act 2018 on the basis of consent, contract, or legitimate interest as applicable, and retained only as long as necessary or as required by professional guidelines.

4. My Rights

• I understand I have the right to access, correct, or request deletion of my personal information, subject to professional record-keeping obligations, and may raise concerns with the Information Commissioner's Office (ICO).

5. Sharing of Information

• Information is shared with other parties only with my consent, where necessary for my care, or as required by law.

Client Information

• Full NameText
• Phone / EmailText

Provider Information

• Provider NameText
• Data Protection ContactText

Emergency Contact

• Contact NameText
• Relationship / PhoneText

Acknowledgment and Signature

• Client SignatureSignature
• Date signed (client)Date

• By signing below, I confirm I have received, read, and understood this privacy notice.