Client Registration form Thank you for completing this registration form. This information is required before we are allowed to provide care. 1. Title and Full name 2. Date of Birth 3. Full Address 4. Telephone Numbers – (i) Mobile - (ii) Landline - 5. Your preferred e-mail address- Please repeat your preferred e-mail address- 6. GP name and address 7.Please click if you are funding the appointment yourself or have an insurer who has agreed to pay? Funding myself Insurance New appointments are £295 and follow-ups are £200. Name of insurer Your policy number Insurer’s approval code 8. Next of Kin (if known) 9. NHS number if you have it 10. Please attach any referral letter you may have 11. If you don’t already have an appointment to see Mr Thiagamoorthy, When and where would you want an appointment with Mr Thiagamoorthy (you may already have one)? I already have an appointment reserved As soon as possible at either hospital Alternate Monday AM at BMI Runnymede Hospital Alternate Tuesday AM at Woking Nuffield Hospital PM in either hospital Virtual (telephone) Submit