Private Practice Registration Form

Please 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 will take about 5 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
How 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?
It is really important to have a referral letter before
- Yes
- No
- Not sure or waiting on one from GP
Please 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.
- Yes
- No
Please upload any other documents here (max of 10 files)
Drop files here or
Your Address
Please enter your postal address for correspondence

Street Address Address Line 2 City ZIP / Postal Code Country
Name of your General Practitioner (GP)
Your GPs Name
Your GPs Surgery Name or Address
When you click submit I will telephone you for an initial assessment of your symptoms. Telephone calls are normally made between 6 and 9pm weekdays or 9am-12midday on Saturdays. 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 know and understand that a minimum fee of £50.00 is payable in the event that a face to face appointment is not required. I agree to my information being shared with second parties for the sole purpose of administering this private consultation service, including secretarial support, invoicing and bill payments. 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).
Email
This field is for validation purposes and should be left unchanged.