Name *

First Name

Last Name

Title

Miss

Mrs

Ms

Master

Mr

Sir

Honourable

Lady

Dr

Professor

Date of Birth

MM

DD

YYYY

Mobile

(###)

###

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Landline Number

(###)

###

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Consent to Terms and Conditions *

I confirm that, to the best of my knowledge and belief, the information I have given on this form is true and correct. I consent to all relevant medical records and images being stored digitally by London Hear Care until I notify you otherwise. I hereby undertake to pay London Hear Care for services & materials relating to my/my child's treatment as a private patient, including any circumstances where medical insurance proves not to cover the specific course of treatment, in which case I agree to settle my account upon receipt of invoice (please note that any additional costs incurred by London Hear Care in obtaining payment will be added to your account.)

I hereby consent