Insurance Form

Title

Forename(s)

Surname

Date of Birth

Home Phone Number

Mobile

UK Address

Overseas Address (if applicable)

Who Referred You?

GP/Specialist Details

GP/Surgery Name

Specialist Name (if any)

GP Address

Specialist Address

Are you allergic to any medication?

If yes, please list...

Do you take any regular medication?

If yes, please list...

Payment Details

Insurer Name

Membership Number

Authourisation Code:

Payment Responsibility

I understand that if my insurance does not cover or fully pay for my visit or services, I am responsible for the remaining balance. I authorise 108 Medical Limited to charge my card on file for any unpaid amounts

spacer

Did you receive a confirmation email for your appointment?

Yes No

Would you like a chaperone to sit in your appointment?

Yes No

spacer

Do you consent for us to send your GP/Consultant/Insurance Company a copy of your clinic letter/report?

Yes No

We strongly recommend

We strongly recommend you tick YES so we can provide you and your medical team with the best of care. To tick NO may compromise your care and cause implications if we cannot communicate with your medical team. It is important for your Consultant/GP to receive all copies of your letters and reports

spacer

Would you like a copy of your clinic letter/report?

Yes No

To be completed by breast patient only

Please provide the date of your last breast screening appointment (if applicable)

Address/Name of Clinic/Hospital

Do you consent for us to obtain and upload your previous imaging onto our database?

Yes No

To be completed by breast patient only

Men's Health Patients

Would you like an annual reminder for your prostate check?

Yes No

Are you happy for us to use your feedback anonymously on our website?

Yes No

Signature

Date

Pay my Bill

Book an Appointment

GP/Specialist Details

Payment Details

To be completed by breast patient only

Men's Health Patients

Clinics

Helpful Links

Insurance Form

GP/Specialist Details

Payment Details

To be completed by breast patient only

Men's Health Patients

Search