Private Practice Registration Form

Dr Raeburn Forbes Consultant Neurologist

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 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
YYYY
Health 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.
If you have one, please enter Membership Number or Authorisation Number
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?
Please upload a referral letter or make sure you have one when you attend a face to face appointment.
- 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 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).
Comments
This field is for validation purposes and should be left unchanged.

<! –