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

First Name

Last Name

Contact No.

Date of birth

Address with postcode

Insurer

AXA Health

Aviva

Vitality

BUPA

CIGNA

Membership number

If AXA, 7 digit and a letter at the end

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 paid fully to Lavender on the Hill or if there are any excess, the registered card will be charged for the shortfall.

Signed (Print name) :

Date:

Private Medical Insurance

Lavender on The Hill Locations