Registration Form

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

GP Details

Insurance Details

(please contact your insurance prior to the appointment)

Do you have an excess?*
YesNo

Terms and Cancellation Policy
First assessment consultation (55 minutes) £550.00
Follow up appointment of 30min £260.00
Follow up appointment of 55 minutes £400.00
Prescriptions issued outside appointment : £50.00
• Medical reports will be charged separately
• The client is responsible if insurance fails
• Self-funding patients are required to settle their account either before or at the end of their consultation.
• Dr Bernat will accept payment by Bacs, cheque, cash or card. Payment by phone please call 020 8441 5241
• All financial matters are dealt with by a third party who will contact you on my behalf regarding outstanding payments.
• A 24 hour notice of cancellation is required, otherwise full charges are applicable.
Failure to make payment within 14 days will result in the matter being referred to Debt Collection Agents whose charges will be added to and payable with the invoice debt.

Please select to accept the above terms and cancellation policy*

Consent for Information Sharing

It is good medical practice to communicate with other professionals involved in your care so as to ensure the best possible treatment outcomes.

Dr Bernat will discuss with you a wide range of issues during the consultation. Her normal practice is to prepare a report based on your consultation with a diagnosis and treatment plan to be sent to your GP, Consultant or any other medical professional or Therapist involved, with a copy to yourself.

Please complete, sign the form, date it and send by post or submit electronically to Dr Bernat, if you give consent for information to be shared with professionals involved in your care AND if you read carefully my privacy policy.

Please also note that if you are willing to be insured by a private health insurance, it will become necessary for me to communicate with the insurance company about your care as well as for my billing team tocommunicate with the insurance regarding financial matters.

Please note that my billing team will have access to your financial details and will also communicate directly with you.

Please let me know if you object to any form of contact between us, either via email or post. Otherwise I will assume that you do not object to communication either via email, post, SMS, or any other way.

Please read carefully my privacy policy

Thanks for your cooperation.

Dr Bernat will discuss with you a wide range of issues. Her normal practice is to prepare a report based on your consultation with a diagnosis and treatment plan to be sent to your GP, Consultant or any other Therapist involved, with a copy to yourself.

Please sign the form, date it and send to me at The Priory Hospital North London if you give consent for information to be shared with professionals involved in your care.

* indicates required field

Please select to accept sharing information and submit form electronically by email to: DrBernat@FemalePsychiatristLondon.co.uk

Yes *