Acceptance form for an Appointment
Dr Mark Gompels MD FRCP FRCPath
C/O Southmead Hospital
Department of Immunology
New Pathology Sciences Building
Westbury on Trym
Name .. Date of Birth ..
Insurance Company details or self funded (please delete)
Company name and address ...
Telephone number ..
Policy number .
Authorisation number .
Claim number .
Card Number .
Card Type: Visa/ Mastercard etc .........
Name on card ...
I agree to my card being charged for a fee of up to £35 if I do not cancel my appointment and do not attend.
Signed Date .
· On arrival please let the receptionist know that you have arrived. There may be a short wait.
· A consultation will normally last up to 30 minutes. It will comprise of an interview with a specialist Nurse and a Consultant
· Following this you may be recommended to have some tests including allergy tests and blood tests.
· The Doctor will then provide you with a report, a copy of which will be sent to you and a copy to your registered GP.
· There will be a charge of £210 for your consultation (this includes room hire, secretarial and other costs), £95 for skin tests and/or interpretation of blood tests and you will be given a price for the other tests on request. You are responsible for the tests fee if not covered by your insurance.
· Following the report you will be either be asked to re attend for a further appointment or your care handed back to the GP.
· It will be necessary to charge for follow up appointments, additional consultations etc. This will be at the same rate and the same time allocated as your first appointment.
· Depending on your insurance company you may need prior authorisation and you may have a voluntary excess to pay, or pay for any underfunding.
· No treatment costs are included in the fee. If a treatment is necessary then a private prescription can be issued. It may be possible to discuss with your GP if they are willing to provide the recommended treatment.
· In accepting this appointment I agree for my details to be stored and transferred electronically for the sole purpose of providing me with a medical opinion. I understand that this information may be provided to another member of the healthcare profession should they need to access it for the purpose of my medical treatment. I agree for this information to be stored for the statutory time for all medical records.