Patient Agreement and Consent Form

Patient Agreement and Consent Form

The UK ME/CFS specialist clinic (Operated by DVSP ltd): Specialist Medical Assessment and Management of ME/CFS (Myalgic Encephalomyelitis/Chronic Fatigue Syndrome), Fibromyalgia and Long COVID (post-COVID syndrome). 

This document outlines the terms of service, financial agreement, and provides the necessary consent for treatment and data processing at the UK ME/CFS specialist clinic. Please read all sections carefully before signing.

PART A: Agreement for Private Treatment

1. The Service

1.1. I agree to receive specialist medical assessment and management for ME/CFS, Fibromyalgia and Long COVID from Dr. Dmitry Pshezhetskiy (GPwSI in ME/CFS). 1.2. I understand this is a fully private and virtual service delivered via online consultation, operating separately from my NHS GP surgery. 1.3. I confirm that I am an adult (18 years or older) living in the UK and that I have provided a valid referral from my NHS GP. 1.4. I understand that the service is non-urgent. For medical emergencies or acute psychiatric concerns, I must contact my NHS GP, 111, or emergency services (999).

2. Responsibilities of the Patient

2.1. I agree to provide accurate and complete medical information to Dr. Pshezhetskiy. 2.2. I agree to inform the Clinic immediately if my condition significantly changes, or if I receive conflicting medical advice from another healthcare provider. 2.3. I understand that my care plan is based on the current NICE Guidelines and requires my active participation, particularly in relation to energy management and pacing.

3. Service Limitations

3.1. I understand that this service does not include physical examinations, diagnostic imaging, or blood tests (except where arranged separately by my NHS GP or other private arrangement). 3.2. I acknowledge that the outcomes of ME/CFS, Fibromyalgia and Long COVID treatment can vary widely and that no guarantee of recovery or specific improvement is provided.

PART B: Financial Agreement

1. Fees and Payment

1.1. I understand that the Clinic operates on a fee-paying basis and is not covered by the NHS. 1.2. Current Fees (Subject to Change):  Initial 45-Minute Consultation: GBP 300 Follow-Up 30-Minute Consultation: GBP 150 Prescription Issuing Fee (per request outside of consultation): GBP 40 Detailed Report/Letter Fee (e.g., for insurance, employer)(required initial consultation): GBP 150 1.3. I agree to pay all fees in advance of the scheduled appointment time. Failure to pay will result in automatic cancellation of the appointment.

2. Cancellations and Rescheduling

2.1. I understand that cancellations or rescheduling requests must be made with a minimum of 2 weeks’ notice. 2.2. If I cancel or reschedule with less than 2 weeks’ notice, or if I fail to attend (DNA) the scheduled virtual consultation, the full fee for the appointment will be retained by the Clinic. 2.3. If the clinician needs to cancel an appointment, the fee will be fully refunded or credited toward the next appointment.

PART C: Consent for Data Processing and Sharing

I acknowledge that I have read and understood the Clinic's Private Patient Privacy Notice.

1. Explicit Consent for Data Sharing with NHS GP (Mandatory)

Purpose: To ensure the safety of your care, to prevent conflicting treatment advice, and to maintain seamless communication with your main healthcare provider.

I explicitly consent to the following:

• The initial assessment and diagnosis will be communicated to my registered NHS GP.

• Significant changes to my treatment plan or medication recommendations will be communicated to my registered NHS GP.

• Discharge summaries or formal closing reports will be sent to my registered NHS GP.

I understand that without this explicit consent for communication with my NHS GP, the Clinic cannot safely provide specialist care, and the agreement for treatment may be terminated.

2. Consent for Processing Special Category Data

I consent to the Clinic collecting and processing my Special Category Health Data (including my ME/CFS diagnosis, medical history, clinical notes, and treatment plans) for the purpose of providing me with healthcare services, as outlined in the Clinic's Privacy Notice.

3. Consent for Communication

I consent to the Clinic using the contact details I have provided (email, phone, address) for the purposes of appointment scheduling, sending consultation links, payment reminders, and delivering medical reports.

Declaration and Signature

I confirm that I have read and understood all sections of this Patient Agreement and Consent Form, including the terms of service, the financial agreement, and the explicit consent required for data sharing. I agree to be bound by these terms.

Please retain a copy of this signed form and the Privacy Notice for your records.