108 Harley Street – Registration Form

Patient Details

Full Name*

Date of Birth*

UK Address*

Overseas Address (if any)

Email address*

Contact number*

Next of kin*

Next of kin Contact Number*

Who referred you to 108 Harley Street

GP/Specialist Details

GP/Surgery Name

GP Address

Specialist Name (if any)

Specialist Address

Payment Details

Payment Type
—Self FundingInsuranceEmbassyOther

Please complete below as appropriate:

Appointment Details

Did you receive a confirmation email for your appointment?
YesNo

Would you like a chaperone to sit in your appointment?
YesNo

Please List Allergies (If any)

Please list any current medication (If any)

Please list any anticoagulant (blood thinning) drugs (If any)

Would you like an annual follow-up reminder for breast check-up and screening?
YesNo

Do you consent for us to send your GP/Consultant/Insurance Company a copy of your clinic letter/report. (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)
YesNo

Would you like a copy of your clinic letter?
YesNo

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

Date of your last breast screening appointment (If applicable)

Address/Name of Clinic/Hospital for your last breast screening appointment (If applicable)

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

If required, do you consent for your images to be sent to other medical organisations?
YesNo

I give permission to store and process the above data