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Out of Hours
info@108harleystreet.co.uk
+44 (0) 207 563 1234
Out of Hours
info@108harleystreet.co.uk
+44 (0) 207 563 1234
Clinics
Health
For Patients
For Doctors
About
Team Directory
Charity
Clinics
Health
For Patients
For Doctors
About
Team Directory
Charity
Pay my Bill
Book an Appointment
Clinics
Health
For Patients
For Doctors
Pay My Bill
Book an Appointment
Charity
Out of Hours
Clinics
Health
For Patients
For Doctors
Pay My Bill
Book an Appointment
Charity
Out of Hours
Self Paying Form
Title
Mr.
Mrs.
Ms.
Miss
Mx.
Dr.
Prof.
Sir
Forename(s)
Surname
Date of Birth
Home Phone Number
Mobile
UK Address
Overseas Address
(if applicable)
Email
Who Referred You?
Next of Kin/Emergency Contact
Telephone Number
GP/Specialist Details
GP/Specialist Details
GP/Surgery Name
Specialist Name (if any)
GP Address
Specialist Address
Are you allergic to any medication?
Yes
No
If yes, please list...
Do you take any regular medication?
Yes
No
If yes, please list...
Payment Details
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
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
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
Send
Search
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