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Outpatient booking form

This form is for medical professionals only.

Please complete this outpatient procedure booking form. A member of the appointments team will be in touch shortly to confirm your booking.

If you would like to speak to a member of the outpatient appointments team, please contact us on:

London: Email us or call 0207 079 2100

Essex: Email us or call 01245 801 234

Select A Location

25 Harley Street

Phoenix Hospital Chelmsford

Patient Details

Title*

First Name*

Last Name*

Date of Birth*

Email*

Phone Number*

Residential address*

Postcode*

NHS Number (if applicable)

Admission Details

Consultant

Support staff needed

Date of admission*

Time of admission*

Procedure(s)*

OPCS code

Estimated procedure length*

Payment Details

Payment type*

Price confirmed with bookings team?*

Yes

Procedure amount (please give breakdown)

Membership no.

Authorisation code

Insurance company (required if Insurance is selected)

Embassy (required if Embassy is selected)

Letter of guarantee?*

Yes

Extra Requirements

Equipment and consumables needed

Medication required

Prosthesis/Implant(s) requirements ie Mirena Coil, Earfold

Investigations required ie Pathology/Flow Rate

Histology

Physiotherapy*

Dietary / Allergies

Wheelchair Access

Other

Please upload supporting clinic letter*:

For office use

INS / FEE

Completed By

Full name*

Email address*

Number*

Date*

If you are happy to receive information on our healthcare services please tick here

we will never share your details and will only send you information about our healthcare services

Please leave this field empty.