Agreement for services form

Please ensure you have read the following information before completing the form below.

Patient details

Title(Required)

Forename(s)(Required)

Surname(Required)

Contact telephone(Required)

Mobile telephone

Date of Birth(Required)

Address(Required)

Address Line 1 Address Line 2 City Postcode

Email address(Required)

Name of private consultant

Admission/attendance date

Are you submitting this for yourself or on behalf of someone?(Required)

For yourself

Behalf of someone

Other contact details or if someone is paying on your behalf

Title(Required)

Forename(s)(Required)

Surname(Required)

Contact telephone(Required)

Mobile telephone

Address(Required)

Address Line 1 Address Line 2 City Postcode

Email address(Required)

Relationship to patient(Required)

Medical insurance details

Are you medically insured?(Required)

Yes

If you are paying for your treatment, please refer to the ‘Ways to Pay’ information sheet included with your letter. If you wish to contact us regarding payment, please ring 0191 282 0839 or 0191 282 0592 or email us at [email protected]

If you are medically insured, please complete below

Insurer's name(Required)

Membership number(Required)

Authorisation number

Authorisation length of stay

Do you consent to your personal data being shared to PHIN for the purposes of the ADAPt programme.(Required)

Yes

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Agreement for services form

Patient details

Other contact details or if someone is paying on your behalf

Medical insurance details

If you are medically insured, please complete below