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)

Please select(Required)

I already have an appointment

I would like to make an appointment

Please confirm your Appointment Date(Required)

Please confirm your Appointment Time(Required)

Appointment Location(Required)

Appointment Date(Required)

Appointment Time(Required)

Preferred treatment centre(Required)

The 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 Details

Gender @ birth(Required)

Title(Required)

First Name(Required)

Last Name(Required)

DoB(Required)

Occupation(Required)

Building Name or Number(Required)

Street or Road Name(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)

Axa 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.

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:

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:

Referred by(Required)

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 fail to attend or 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.

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. PLEASE ENSURE THAT YOU SPEAK TO YOUR INSURER AND SECURE AN AUTHORISATION SPECIFICALLY FOR THE SPECIALIST YOU ARE SEEING FOR THIS APPOINTMENT.

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.

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.

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.

Please attach relevant pictures, report, authorisation and referral letters, etc.

Drop files here or

Accepted file types: jpg, jpeg, bmp, gif, png, webp, pdf, doc, docx, rtf, odt, Max. file size: 24 MB, Max. files: 10.

Signature(Required)

Name

This field is for validation purposes and should be left unchanged.