Registration Form

If your enquiry is related to ADHD please contact the clinic on 02084415241 before filling in these forms

Registration Form

When completed click the submit
button and the form will be emailed;

* indicates required field

Your Details

Title*

Your Name

Date of Birth

Your Address

Your Mobile

Your Email

Do you give consent to be contacted by email

Yes No

Next of Kin details

Next of Kin

Relationship to you

Contact Number

Do you give consent for information to be shared with your next of kin?

Yes No

GP details

Name

Address

Telephone Number

Email address

Do you give consent for us to correspond and share information with your gp

Yes No

Personal Data

We use Egress which is a secure platform to send your medical data to your insurers/practitioners/ who may be involved in your care. You will also receive a copy of this data via Egress. We recommend that you download and save any letters received from us for your records as they are only accessible for a limited time.

Insurance Details

(please contact your insurance prior to the appointment)

Insurers Name

Membership Number

Authorisation Number

Do you have an excess?*

Do you give consent for information to be shared with your insurers?

Yes No

Information Sharing

Do you give consent to us sharing your information with other professionals or professional bodies for the purposes of referring you

Information sharing

Yes No

Accepted Terms

I have read, understood, and agree with the above.*

Date

Terms and Conditions

Please note that the commercial contract is between patient and professional, and you are responsible for payment should your insurers fail to pay the bill in full. By filling these forms, you are agreeing to our terms and conditions regardless of whether or not you have signed them.

Initial Assessment (up to 50 minutes) £550.00
Follow-up (up to 40 minutes) £450.00
Follow-up (up to 25 minutes) £260.00
Repeat prescriptions £40.00

Medical certificates or any correspondence outside clinic time - fee depending on what’s requested.

Cancellations require 24hrs notice (Monday-Friday) otherwise the full cost of the appointment will be non-refundable. Monday morning appts must be cancelled on Friday morning.
If patients are self-funding, payments are to be made at the time of booking the appointment.

In any event of failure to pay, we reserve the right to instruct a third party to recover the debt.

You will always be contacted by the Accounts Team regarding payments.

Payments are made either by credit card via telephone, Sum up payment link or by bank transfer to:

Dr Claudia Bernat Sort code 08-71-99 Account 10179123 (T/A Ellesmere Clinic Ltd)

Your Name

Your Address

Telephone

I have read, understood, and agree with the above.

Date