Dr Maxton Pitcher MA MD BM BCh FRCP

Consultant Gastroenterologist
www.harrowgastro.co.uk
Private Outpatient Registration Form

PATIENT DETAILS

Patient name…Shailendra Singh GP details…R.K Singh 65 Clifford Rd, Hounslow West…………………………………………………

Date of birth…02/02/1979…………………………………………………….
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Address………185 Beavers Lane Hounslow TW4 6HG…………………………………...………………..

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Home phone………………………….

Mobile…………………07735461192……………….

Work……………………………………

Email address……………03oct1978@gmail.com…………………………………

NHS Number……649 905 9609……………………………………………….

INSURANCE DETAILS

Insurance / Vitality insurance private healthcare.care care number 9816542

Medical Insurer’s name……………………………………….

Membership number………………………………………….

Pre-authorisation number……………………………………

Do you have an excess on your policy? No Yes £……………./ No (please circle)

Do you have an AXA PPP “six week” clause on your policy? Yes / No (please circle)

PROFESSIONAL FEES FOR SELF-PAY PATIENTS - Payment by credit card will be requested in advance of/at the consultation

New consultation £250 (telephone/video/face to face)

Follow-up consultation £180

BMI, OneWelbeck and St Mark’s Private Healthcare/Trustplus have a fixed price self-pay tariff for endoscopic procedures
which Dr Pitcher can advise on