Registration Form

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

* indicates required field

Your details

Your Name

Date

Date of Birth

Telephone

Mobile

Email*

Address

Address2

City

Postcode

Referred by

GP Details

GP Name

GP Telephone

GP Address

GP Address2

GP City

GP Postcode

Insurance Details

(please contact your insurance prior to the appointment)

Insurers Name

Membership Number

Authorisation Number

Do you have an excess?*

Yes No

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.

Please select to accept the above terms and cancellation policy*