THE LONDON COLORECTAL CLINIC
CONSIDERING NHS TO PRIVATE CARE
Name
Date of Birth
Sex
Female
Male
Prefer not to say
Address
Phone Number
Email
What is the purpose of contacting us?
Seek a quicker private specialist consultation?
Have investigations done privately which have been requested under the NHS?
Have treatment done privately which you are currently awaiting for in the NHS?
Seek a second opinion to review your NHS treatment to date?
Would you like a quote for our investigations & treatments?
Type of Consultation Request
A member of the appointments team at will contact you to schedule an appointment with Mr Nunoo-Mensah
Physical Consultation request
Telephone Consultation request
Virtual/Video Consultation request
Consultation Location
A member of the appointments team at will contact you to schedule an appointment with Mr Nunoo-Mensah
Cleveland Clinic London - 33 Grosvenor Pl, London SW1X 7HY (Appointments on Thursday's & Friday's)
Guthrie Clinic - King's College Hospital , London, SE5 9AE (Appointments on Wednesdays)
Either Cleveland Clinic London or Guthrie Clinic, King's College Hospital
Are you covering the cost of your consultation with a private health insurance policy?
Yes
No
Please submit the private insurance company name, your policy number and authorization number
Are you covering the cost of your consultation as a self paying patient?
Yes
No
If you will be covering the cost of your consultation by other means please specify.
Please provided information of investigations and treatments you would like us to provide a quote as a self paying patient.
File upload any referral letters,results relevant to the consulation etc
Delete all uploads
Choose files or drag here
Additional Information
Verification
SUBMIT FORM
Please wait...
Save for later
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20