Patient Details Form

Mr. Stephenson's Private Clinic

Title

First Name(s):

Surname:

Maiden Name (if applicable):

Date of birth:

Parent's name if the patient is under 18 years of age:

Address Line 1:

Address Line 2:

Parish:

Postcode:

Email:

Telephone Number:

Mobile:

Work Number:

Occupation:

GP's Name and Practice:

Allergies:

Medical Insurance:

Name of Insurance Company:

If Other:

Note

Please note that we will try our best to settle the accounts directly with your insurer, however if there are any problems we will ask you to contact your insurance company and settle any disputes with them. Due to ongoing issues specifically with BUPA we no longer send invoices directly to them, therefore if you are insured with BUPA the bill will be sent to you to arrange payment.

Membership Number:

Pre-Authorization Number:

Permission

It is thought to be a good idea if your medical history with details of operations for example, are kept in your General Hospital notes as well as there being a record in your private notes in our office. This is in case you are admitted as an emergency when the private notes may not be readily available. Please state that you are prepared for your private notes to be copied into the Hospital general notes.