Patient registration form – Self funding

To complete the registration process, can you please review the Terms and conditions which have already been provided to you by email and complete the registration form. Once we receive the completed information one of our representatives will get in touch with you promptly.

Sciensus – Patient registration form – Self funding

Patient information

Name(Required)

Title First Name Last Name

Date of birth(Required)

Gender at birth(Required)

Male

Female

NHS number (If known)

Address(Required)

Street Address Address Line 2 City Region Postal code Country

Telephone(Required)

Mobile

Email(Required)

Enter Email Confirm Email

Method of payment(Required)

Bank transfer via BACS: Sciensus Pharma Services Limited – Account No: 47861452 Sort code: 60-03-23 Iban: GB81NWBK60032347861452 BIC/SWIFT: NWBKGB2L. Please reference patient MRN number when making a payment.

Card payment (over the phone): 0333 2079376

Emergency contact details

Name(Required)

Title First Name Last Name

Address(Required)

Street Address Address Line 2 City Region Postal code Country

Contact number(Required)

Relationship to patient(Required)

GP Information

GP Name(Required)

GP Address(Required)

Street Address Address Line 2 City Region Postal code Country

GP contact number(Required)

Consent

I confirm that:(Required)

A) The information given in this form is correct and I will notify Sciensus if my details change.

B) I have received the Sciensus Terms and Conditions for Private Patients and acknowledge these will apply to the Services provided to me.

Date

Name

This field is for validation purposes and should be left unchanged.