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

Bristol, BS10 5NB

Tel: 0345450044

email: info@southwestallergy.co.uk

 

 

Name …………………………………………….. Date of Birth……………………..

 

 

Address …………………………………………………………………………………

 

Home telephone no……………………………..  Mobile no………………………….

 

E-mail address …………………………………………………………………………

 

GP details ………………………………………………………………………………

 

…………………………………………………………………………………………..

 

Insurance Company details or self funded (please delete) –

 

Company name and address…………………………………………………………...

 

…………………………………………………………………………………………..

 

Telephone number ……………………………………………………………………..

 

Policy number ………………………………………………………………………….

 

Authorisation number………………………………………………………………….

 

Claim number ………………………………………………………………………….

 

 

To confirm your appointment, we need a credit card deposit -

 

Card Number ………………………………………………………………………….

Card Type:  Visa/ Mastercard etc ……………………………………………….........

Expiry date……………………………………………………………………………

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 ……………………………….

 

Your Appointment

 

·        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.