Patient registration form – Third party 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 – Third party 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

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)

Information on funding company

Company name(Required)

Address(Required)

Street Address Address Line 2 City Region Postal code Country

Phone(Required)

Reference number (if known)

Relationship to patient(Required)

Solicitor

Defendant

Employer

Family member

Other

If other – please confirm

GP information

GP name(Required)

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(Required)

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