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Once you have booked your appointment, please complete this form and submit it to register as a patient at Bupa Cromwell Hospital.
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All patients / patient payor / representative
In consideration of the hospital accepting me/the patient for nursing care and accommodation, I/we undertake to pay all services rendered and items supplied to me/the patient in accordance with the hospital's charges applicable at the time of treatment, including all personal expenses, such as telephone calls, take home medication, supplies and catering for relatives etc. I acknowledge that I remain liable for such payment, whether or not I/ the patient have/has medical insurance or third party sponsorship in respect of some or all of the services provided and items supplied. If following discharge there is a shortfall or excess due to the Hospital, I accept that I/the patient will be invoiced for this sum and I hereby agree to pay this direct to the Hospital.
I acknowledge that the consultant / specialist is not an employee or agent of the hospital and that, unless otherwise stated, he/she will invoice me/the patient separately for their services, which I am responsible to pay to him/her directly.
DATA PROTECTION NOTICE
For further information please refer to the Data Protection and Your Information leaflet.
Medical information will be kept confidential. It will only be disclosed to those involved with the provision of your treatment or care, or to their agents, and, if applicable, to any person or organisation who may be responsible for meeting your treatment expenses, or their agents.
Bupa Cromwell Hospital is committed to continuous improvement. Your medical care information may be used for audit and quality monitoring, some of which will be independently audited. Where it is not possible to use anonymised information, personal identifiable information may be used for essential purposes and will comply with the Data Protection Act 1998.