Title*

First Name*

Surname*

Address*

Postcode*

Date of Birth*

Email Address*

Mobile Number*

How did you hear about this clinic?*

Previous patient name

If other

Consultant Name

Body part being treated*

GP Name

GP Address

If required, do you give consent for us to correspond with your referring consultant, GP or insurer?*

Yes

No

We send a monthly health newsletter to all of our patients. Would you like to receive this?*

Yes

No

INSURANCE

We only have direct billing agreements with AXA/PPP and Bupa.Other insurers: Payment must be made at time of each appointment. We will provide an itemised invoice in order for you to claim reimbursement directly.

Are you covered by AXA/PPP, Bupa, WPA and Aviva insurance?*

Yes

No

Name of Insurance Company

Policy Number

Authorisation Code

Sessions Authorised

We are unable to invoice BUPA or AXA directly unless you have a valid authorisation code. *

In the event your insurer rejects a payment – for instance if an excess is due – you are required to settle your account directly with us.*

Under our contracts with BUPA and AXA, we offer discounted rates for sessions authorised by your insurer. However, upon completion of your authorised sessions, any subsequent sessions will be billed at our normal rate, and will require payment directly to the clinic. *

CONSENT AND CANCELLATION POLICY

I understand that I am responsible for the full cost of my treatment, and agree to pay the fees for treatment at the end of each appointment.I understand that should I fail to attend an appointment without 24 hours notice I will be liable for the full cost of the treatment.

Signature

Patient Registration

INSURANCE

Insurance Details

CONSENT AND CANCELLATION POLICY