Private Medical Insurance

If you have a pre-approved insurance treatment, please complete your details below.

Personal Details (as per insurance policy)

If minor, please complete this form by someone with parental responsibility and/or legal guardian. All details below must be completed for the patient that will be undergoing treatment.

Full Name Per Insurance Policy

First Name

Last Name

Contact No.

Date of Birth

Full Address with Postcode

Insurer

AXA

Aviva

BUPA

Vitality

Cigna

Membership number

If AXA, 7 digit and a letter at the end

Pre-Authorisation Number / Claim Number

Number of Sessions Approved

Main Issue Requiring Treatment:

Renewal Date (if known):

Authorisation

I confirm that I have obtained pre-authorisation from my Private Medical Insurance. If the claim is not fully paid to Lavender on the Hill or if there are any excess to pay, the registered card will be charged for the shortfall. I am the registered cardholder and responsible for the shortfall in payment.

Date:

Signed (Print name):

Private Medical Insurance

Lavender on The Hill Locations