New Patient Registration Form

Patient Details:

Name:*

Prefix First Last

Date of Birth*

MM

DD

YYYY

dd/mm/yyyy

Phone Number:*

Home Address*

Street Address Address Line 2 City Post Code

Email*

Enter Email Confirm Email

How will your treatment be funded?

Please tell us who will be paying for your treatment.*

Self-Funding
Private Healthcare Insurer

Who is Your Healthcare Provider?*

Please select one provider from the list above.

If your Provider is not on the list, tell us who it is here:

Private Healthcare Authorisation Code:

If you are using Private Healthcare, please contact your provider to obtain this number.

GP's Details:

We will only use this information in case of an emergency and we would always try to contact you first.

Name

First Last

Address of GP Practice:

Street Address Address Line 2 City State / Province / Region Post Code

GP Practice Telephone Number:

CBT Clinic London Policy on Missed or Cancelled Appointments

Please read carefully the policy on our website and tick the box below to confirm that you agree to comply with our terms and conditions in relation to Missed or Cancelled Appointments - Thank you.

Terms and Conditions:*

I have read and agree to comply with the CBT Clinic London's policy on Missed or Cancelled Appointments .

How did you come to hear about us?

Please help us by checking one of the boxes below - Thank you.