registration form 002 copy

Dr Ghazala Afzal
Patient Registration Form
Name:
Date:
Address:
Date of Birth:
Telephone:
Mobile:
Parent/Carer Details
Name:
Name:
Contact No.:
Contact No.:
Referred By
GP Details
Name:
Telephone:
GP Address:
School
Name:
Telephone:
Who lives at Home (and relationship to index patient):
Insurance Details (if applicable):
Terms and Cancellation Policy
•
•
•
•
A 24 hour notice of cancellation is required, otherwise full charges are applicable.
Prescriptions via telephone consultations will be charged.
The client is responsible for payment if Insurance fails.
Failure to make payment within 28 days will result in the matter being referred to Debt
Collection Agents whose charges will be added to and payable with the invoice debt.
Signature (Fax Submission 020 7034 4490):
✔
Please select to accept above Terms and Cancellation Policy and submit form electronically