Self Paying Form

Title

Forename(s)

Surname

Date of Birth

Home Phone Number

Mobile

UK Address

Overseas Address (if applicable)

Who Referred You?

Next of Kin/Emergency Contact

Telephone Number

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

We strongly recommend

Self-Pay Financial Responsibility
I understand that I am a self-pay patient and that payment is my responsibility. I agree to pay for all services rendered by 108 Medical Limited. I authorise this practice to charge my card on file for any outstanding balances.

Signature

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Did you receive a confirmation email for your appointment?

Yes No

Would you like a chaperone to sit in your appointment?

Yes No

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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

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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

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

I confirm that the information I have provided in this form is complete and accurate to the best of my knowledge.

By typing my full name below and submitting this form, I confirm that:

I am the person named in this form, or I am authorised to complete it on their behalf;
I understand that my typed name constitutes my electronic signature;
I intend my electronic signature to authenticate and confirm the information provided; and
I consent to this information and my electronic signature being supplied to the relevant insurer, insurance broker or authorised third party for the purpose of arranging, administering or verifying insurance cover.

Signature

Date

I have read and agree to the declaration above and understand that typing my name constitutes my electronic signature.

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

Self Paying Form

GP/Specialist Details

Payment Details

To be completed by breast patient only

Men's Health Patients

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