The London Colorectal Clinic - TELEPHONE/WEB CONSULTATION FORM

IMPORTANT INFORMATION ABOUT TELEPHONE/WEB CONSULTATIONS In line with the government advise to reducing travelling and physical contact unless necessary, we are aware that some patients may still need a consultation to reassure or to commence urgent investigations. At The London Colorectal Clinic, we are now able to perform a telephone or web conference consultation on Monday am or Wed pm. The 15-30min telephone or web consultations are £175 for self-paying patients. If you need a follow-up outpatient consultation for the physical examination is required then we will take into consideration the fee already paid. For example, a follow-up outpatient consultation will incur an additional consultation fee of £25 + £15 room hire fees. Please note that depending on what equipment is used for your examination there may be additional fees from the hospital. If you have private health insurance we encourage you to discuss with them if they will cover the cost of your telephone or web conference consultation. Historically insurance companies have never been too keen on reimbursing practitioners for telephone or virtual consultation but with the current situation of the need to reduce physical contacts this situation is set to change. AXA PPP Healthcare & WPA are now authorizing remote consultations

I agree I have read the above important information.

Name

Address

Email

How will you be planning to pay for your consultation?
The 15-30 min telephone or online consultations are £200 for self-paying patients. If an urgent follow-up outpatient consultation for the physical examination is required then we will take into consideration the fee already paid. If you have private health insurance please contact your insurer to obtain authrization for a consultation.

Self-Paying (£175 pre-paid consultation fee) Private Health Insurance Policy (Please consult your insurer to obtain authorization before booking your appointment) Other payment method

If you intend to pay for your consultation with your Private Health Insurance Policy please provide your Policy Membership Number and Authorization Code.

If you intend to pay for your consultation by other means please provide details of this arrangement.

Please provide a brief summary of your symptoms and/or advice required

Please upload any relevant bllod test results, imaging reports, previous relevant correspondence or GP referral letter

Add files

Drop files anywhere to add

Terms of Service 1. Please Fill in the above form and provide as much information or reports, test etc which will enhance the consultation. 2. If you are based in a EU/UK country we will opt to perform a telephone consultation. If you are based elsewhere abroad we will send you a web based link for the consultation 3. For self-paying patients a consultation fee of £175 will need to be paid prior to your consultation. 4. Cancellation of appointment may be made for 24 hours before your scheduled appointment for a full refund. Thereafter a refund of 50% will be made.

I agree to the terms of service.

Verification