Patient Application Forms

Before an appointment can be made at our clinic, we must have received a completed Patient Application Form.

This can be downloaded here for your convenience. Please choose the format that is most suitable for you (Microsoft Word document or Adobe PDF file), download and save the document, print it out, and complete and return it to us.

» Patient Application Form [Microsoft Word format]

» Patient Application Form [Adobe PDF format]

Please note that before an appointment can be made we must also have received the following, in addition to the completed Patient Application Form :

• Liver Function blood test result (no more than 6 months old)
• 2 passport photographs (with your name written on the reverse)
• Deposit - £200 deposit required – cheques and postal orders made payable to Dr. J. Revill.

Please also note that the £200 deposit is non refundable unless cancelling an appointment within 4 working days or more.

Once we have received the above forms you may contact us to arrange an appointment time and date. Please be aware that we are an extremely busy clinic and therefore ask that you are punctual in your attendance – if you arrive late we may not be able to see you.

We advise you to have a friend or relative come with you, to drive you, as you may feel unable to go home on your own.

If you inform us incorrectly of your ‘clean’ status and after implantation consequently develop withdrawal symptoms you will be liable for any costs that may be incurred.