Pre-Registration Form *required Title* MrMissMrsMsOther Full Name* Date of Birth* First Line of Address* Second Line of Address Town/City* Postcode* Email* Mobile Number* Home Number Business Number GP Name GP Address NHS Number (if known) Oxford Radcliffe Hospital Number (if known) Insurance Company Policy Number Authorisation Terms & Conditions I understand that if I require further treatment on the NHS after I have been seen as a private patient, I may need to be referred to the NHS via my General Practitioner. I undertake to pay Mr S Winter the full cost of my treatment as a private patient, either personally as a self-paying private patient, or through my private medical insurance company. I understand that should there be any shortfall in payment by my private medical insurance company I will be fully liable for such sums. I acknowledge that the infomation I have provided is accurate to the best of my knowlegde and agree to the terms & conditions