Services for doctors at Harley Street Specialist Hospital

Full name(Required)

Title First Last

Date of birth(Required)

Sex(Required)

Mobile(Required)

Telephone

Email(Required)

Address(Required)

Address Line 1 Address Line 2 City Postcode

Surgeon(Required)

Anaesthetic(Required)

Anaesthetist

Date of admission(Required)

Admission Time(Required)

Procedure Description(Required)

CCSD code(s)(Required)

Estimated Operation Lenth(Required)

Number of Nights Required(Required)

Payment type(Required)

Hospital fee amount

Insurance company

Membership number

Authorisation code

Imaging required(Required)

Additional Imaging (Pre/Post Op)(Required)

Equipment requirements(Required)

Histology Required(Required)

Prothesis/implant(s) requirements(Required)

Investigations on admission(Required)

Interpreter Required(Required)

Wheelchair Access(Required)

Dietary/Allergies(Required)

Completed by(Required)

Date(Required)

Notes

Charges may apply for late cancellation as per our terms and conditions