Pre-Registration Form

Date of Birth*

First Line of Address*

Second Line of Address

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