CMA Registration & Consent Form In order to secure your appointment you MUST complete this form in full before you attend each appointment. This form is an important document and sets out important information that we are required by law to provide you. It also allows you to confirm your details and provide your informed consent. Please complete each section and if you are unsure about anything please contact us. Thank you.Please select your Specialist(Required)Ms. Jyoti Patel, Consultant PodiatristConfirm Specialist(Required) Please tick to confirm this is correct before proceeding(Required)Please select(Required) I already have an appointment I would like to make an appointment Please confirm your Appointment Date(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please confirm your Appointment Time(Required) Hours : Minutes AM PM AM/PM Appointment Location(Required)Bupa Cromwell Hospital, London. SW5 0TUSpire Harpenden Hospital, Hertfordshire. AL5 4BPRivers Hospital, Hertfordshire. CM21 0HHFoot Comfort Centre, Wembley. HA9 7LTHome VisitWard VisitAppointment Date(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Appointment Time(Required) Hours : Minutes AM PM AM/PM Preferred treatment centre(Required)Bupa Cromwell Hospital, London. SW5 0TUSpire Harpenden Hospital, Hertfordshire. AL5 4BPRivers Hospital, Hertfordshire. CM21 0HHFoot Comfort Centre, Wembley. HA9 7LTHome VisitWard VisitThe person completing this form(Required) Patient Parent Guardian Third Party Name of Parent(Required) Name of Guardian(Required) Name of Third Party(Required) Mobile No(Required)Email(Required) Patient DetailsGender @ birth(Required)MaleFemaleUnspecifiedTitle(Required)DrMrMrsMsMxMissMasterOtherFirst Name(Required) Last Name(Required) DoB(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Occupation(Required) Building(Required) Street(Required) Town(Required) Region(Required) Postcode(Required) Phone Mobile(Required)Phone Home Phone Work Email Address(Required) Reason for visit(Required)Payment options(Required) Self-Pay Private Medical Insurance Other Please select your Insurer(Required)AllianzAvivaAxa PPPBupa (UK)Bupa (Global)Bupa (Latin America)Cigna (UK)Cigna (Global)HealixVitalityWPAUnited GlobalAxa PPP does not cover the nonsurgical treatment for the Speciality you have selected. You will therefore be seen as a self-pay and will have to cover the costs of your treatment.Axa PPP terms(Required) I HAVE READ, UNDERSTAND, AND ACCEPT THESE TERMS(Required)Policy No. Membership No.(Required) Authorisation No.(Required) Diagnosis Please read and tick the box to confirm you have read, understand, and accept the terms:Bupa (UK) terms(Required) Bupa UK requires you to have a written referral to see the Specialist you have selected. You must provide a written referral to us prior to or on the day of your attendance. If you do not have a referral or do not provide the written referral you will be asked to make payment on the day as a Self Pay patient according to the charges listed below or advised on the day.(Required)Insurer terms 1(Required) Before proceeding with any treatment I will check to ensure that my medical insurance provider and policy will cover me for the specific specialist and their specialty and the condition for which I am seeking treatment(Required)Insurer terms 2(Required) I give authority to submit invoices directly to my private medical insurer and accept that I am responsible for paying any charges which they do not pay.(Required)Name of Third Party(Required) Address(Required) Mobile No(Required)Email(Required) Please read and tick the box to confirm you have read, understand, and accept the terms:Other Consent(Required) Please note that even if someone else is paying your bill, you are responsible for paying any charges which they do not pay.(Required)Referred by(Required) Self GP (Doctor) Specialist Family Friend Google Yell Other Name of GP(Required) Name of Specialist(Required) Speciality(Required) Please specify(Required) PROFESSIONAL FEES STATEMENT Outpatient consultations will apply whether you see me face-to-face or remotely via text, WhatsApp, video, or any other remote or electronic means. £250 – Initial consultation for up to 30 minutes. A maximum of £375 will be charged for extended appointments £150 – Follow-up consultation for up to 20 minutes. A maximum of £250 will be charged for extended appointments My fees for procedures performed during an outpatient consultation are the following: £225 – Gait Analysis and Footscan pedograph £225 – Surgical debridement of skin lesion(s) if performed within consultation rooms £395 – Nail surgery for single toe £700 – Nail Surgery for two toes done on the same day £POA – Verruca removal: depending on the number of lesions £POA – Dressings are chargeable: depending on the dressing type and quantity provided If you cancel your appointment with less than 24 hours’ notice, a cancellation fee of 100% of the appointment charge will be charged. Following your consultation, you may need certain tests (such as blood tests or imaging, for example, an X-ray, MRI, or CT scan) to help diagnose your condition. If the test is undertaken by the Hospital, and not by me, the fees for those tests will be determined by the Hospital and charged to you, or your private medical insurer, separately. If there are any fees that I will charge in addition to the Hospital charge in relation to any of the tests I advise that you have, I will let you know what those will be.PROFESSIONAL FEES STATEMENT(Required) I HAVE READ, UNDERSTAND, AND ACCEPT THE TERMS OUTLINED IN THIS STATEMENT(Required)PRIVATE MEDICAL INSURANCE STATEMENT Please note that even if you have private medical insurance, you are responsible for paying any charges which they do not pay. You MUST provide or bring with you an authorisation code for the consultation and or treatment, whether you are a new patient to our practice or an existing patient coming to the clinic for a follow-up or new medical problem. Before proceeding with your treatment please ensure your medical insurance policy will cover you for the condition for which you are seeking treatment and the Specialist with whom you have made the appointment. Please check the terms of your policy, the level, and the type of outpatient coverage, including any reimbursement limits and exclusions. Medical durables are usually not covered. The services of the Specialist you have chosen are usually recognised and covered by most UK and International Insurance Companies with the exception of AXA PPP. For Bupa UK policies – a referral letter is compulsory. Without a referral letter, we are unable to send the bill directly to BUPA UK, so you will be asked to settle your bill on the day and a receipt will be emailed to you.PRIVATE MEDICAL INSURANCE STATEMENT(Required) I HAVE READ, UNDERSTAND, AND ACCEPT THE TERMS OUTLINED IN THIS STATEMENT(Required)FINANCIAL INTERESTS STATEMENT We are legally obliged to tell you if we have any financial interests in the Private Hospital(s) you will be seen in or any equipment there. We can confirm the Specialist you are seeing does not have any such financial interests. Quality Information. You can compare independent information about the quality of private treatment offered at the hospital and other private healthcare providers from the Private Healthcare Information Network (PHIN) website: www.phin.org.uk.FINANCIAL INTERESTS STATEMENT(Required) I HAVE READ, UNDERSTAND, AND ACCEPT THE TERMS OUTLINED IN THIS STATEMENT(Required)CONSENT STATEMENT I confirm that I would like to see the Specialist listed above for professional advice and treatment. I confirm that the information I have provided on this form is true and accurate and I have not withheld any information that may be relevant to the service or treatment I am seeking. I confirm that I have read the information given on this form, and understand and accept the Fee Structure, Terms, and Conditions of the Service stated above.CONSENT STATEMENT(Required) I HAVE READ, UNDERSTAND, AND GIVE CONSENT(Required)Please attach relevant pictures, report, authorisation and referral letters, etc. Drop files here or Select files Accepted file types: jpg, jpeg, bmp, gif, png, webp, pdf, doc, docx, rtf, odt, Max. file size: 24 MB, Max. files: 10. Signature(Required)CommentsThis field is for validation purposes and should be left unchanged.