Private Practice Registration FormDr Raeburn Forbes Consultant NeurologistPlease complete this form, remembering to include your email address and best telephone number so I can contact you. If you have a referral letter or other documents you wish to upload, you can do so below. It takes an average of 8 minutes to complete this form. Thank you.Email*NB- This form converts your email address to BLOCK CAPITALS but it will still work Enter Email Confirm Email Contact Telephone*Please enter your best telephone number(s).Name* First Last Date of Birth* DD MM YYYYHealth and Care Number (also called HCN)If you know your 10 digit Health and Care Number please enter it here (it is usually on your referral letter or correspondence from hospital or GP). If you do not know this do not worry.Insurance or Self Funding*Please let me know if you are funding this yourself (50% of patients are self-funding) or you have health insurance cover.I am paying my self (no insurance)AVIVAAXA-PPPBenenden or BUPAVitalityWestfield HealthWPAOther InsuranceI'm not sureIf you have one, please enter Membership Number or Authorisation NumberHow can I help?Please say what symptoms you are needing help with - you can be as short or as long as you wish. This will help me know how much time to allow for your initial telephone call.Do you have a referral letter?Please upload a referral letter or make sure you have one when you attend a face to face appointment.YesNoNot sure or waiting on one from GPPlease upload your referral letter here (if you have one) Drop files here or Do you have any other documents you wish to upload?Please upload any other documents here - please note that file upload limits will not allow CDs of MRI pictures to be uploaded. If you have copies of previous scans please bring them to any face to face appointment.YesNoPlease upload any other documents here (max of 10 files) Drop files here or Your AddressPlease enter your postal address for correspondence Street Address Address Line 2 City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Name of your General Practitioner (GP) Your GPs Name Your GPs Surgery Name or AddressWhen you click submit I will telephone you on Wednesdays between 7-9pm or Saturdays 9am-11am. The telephone number will be 'Caller ID Withheld' or 'Private Number'.Consent* I agree to the being contacted by Dr Raeburn Forbes or a member of his staff for the purposes of a private consultation. I agree to my information being shared with second parties for the sole purpose of administering this private consultation service, including prescriptions, secretarial support, invoicing, bill payments and clinical governance purposes. I understand that invoicing and fee payment is taken on behalf of Dr Forbes by HytheHopes Ltd. I agree that my records will be destroyed seven years after my last consultation or by the age of 25 (whichever is longer).CommentsThis field is for validation purposes and should be left unchanged. <! –