Medical Insurance Patient Remote Consent Form Please fill out the form below. " Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth(dd/mm/yyyy)Address *Address Line 1CityState / Province / RegionPostal CodePreferred Telephone Number *Alternative Telephone NumberEmail *CheckboxesPlease tick if you agree to us contacting you with service updates, information & newsletters & discount codes. We will not share with 3rd parties.G P Practice *Medical Checklist.We ask these questions for your safety. Please contact us or ask at your appointment if you have any queries or are uncertain. Pre-existing medical conditionsSteroid TreatmentEpilepsyCancerHeart/chest conditionPacemakerAnti-coagulant TherapyOsteoporosisMajor AllergiesDiabetesAutoimmune DisordersBlood DisordersHave you had any of the above? If Yes, please select.Pre-existing medical conditions - Female Patient OnlyGynaecological Conditions?HRT?Are you Pregnant?Are you currently seeing your Doctor for any other conditions? If yes please give details:What medication are you currently taking?Please tell us about any recent operations or past operations that might affect your current problemInsurance Company Details *Insurance Company NameInsurance Company AddressAddress Line 1CityState / Province / RegionPostal CodeInsurance Company DetailsPolicy or Membership Number *Policy Expiry Date *Authorisation Number *Excess on Policy (£) *Condition authorised for treatment *Payment Method - Please confirm *Medical InsurnanceThat the details I have supplied are current and correct for this course of treatment. I understand that I may be charged for missed appointments or appointments cancelled at late notice (less than 24 hours) I understand that the clinic will need to correspond with my insurance company about my course of treatment.Date *Please check that all your information is correct before submitting.MessageSubmit