Appointment booking questionnaire

In order to proceed with confirming your appointment, please complete the form below, providing all available information.

We use and process your personal information to provide the services you are referred for. We also use and process your personal information to comply with our legal obligations to maintain clinical records and to maintain information security arrangements of our online platform for clinicians. Your personal data will also be processed for purposes associated with billing your account and record keeping based on our legal obligations and contractual rights. If you would like to know more about how we handle your data, please refer to the Cavendish Imaging Privacy Notice.

Your Name (required)

Your Date of Birth (required)

Your Postcode (required)

Your telephone (required)

Your Email (required)

Referred by (required)

The payment will be settled by (required)
MyselfThe practice, that referred meMy insurer, who has authorised the procedureThird party (e.g. NHS, embassy, solicitor, etc)

If insurance:

If third party:

Additional visitors:

Only one carer, interpreter or legal guardian is permitted to attend our patients’ appointment in order to support them. Please do not attend accompanied by non-essential visitors.

Radiation exposure and benefits:

Patients wishing to know more about the impact of the radiation used during the imaging procedure can refer to the Exposure Information leaflet. Please email us if you have concerns that you would like to discuss prior to your appointment.

I confirm that I have read and understood the information presented

Standard Terms & Conditions:

Cavendish Imaging services and products aim to assist healthcare professionals with diagnosis and treatment planning. Cavendish Imaging is not providing and is not responsible for providing any clinical treatment.

Cavendish Imaging endeavours to provide the very highest quality results, however Cavendish Imaging will not accept any liability for incorrect or incomplete information on the referral form or inappropriate or inadequate patient preparation which may compromise the value of the final results.

Cavendish Imaging endeavours to dispatch the images to the referrer and/or the patient in a timely manner, however e.g. equipment malfunction may introduce delays. Cavendish Imaging reserves the right not to accept referrals in such cases. Also, Cavendish Imaging cannot guarantee when radiology reports and data conversions will be available to the referrers unless the timelines are explicitly agreed in advance. Cavendish Imaging must be notified a full working day in advance if a particular service is required urgently.

Non-attendance to an appointment or cancellation of an appointment less than 1 full working weekday prior to the appointment incurs a non-refundable £50 charge, payable before a new appointment can be booked. Alternatively, providing that the referral is still in-date, patients can use the walk-in services offered only at the Cavendish Imaging Harley (our other branches do not offer a walk-in service), Monday to Friday between 11am and 4pm (except on national holidays and transport strike days).

I understand the Standard Terms & Conditions

Payment and Billing:

Self-pay patients:

Patients who are self-paying for the services that Cavendish Imaging provides, will settle their accounts on the day of their visit at the latest. In case of non-payment, Cavendish Imaging reserves the right not to proceed with the services. If the services are provided, delay in the processing of the order or the delivery of the complete service may occur. In the event of patients having paid for the services in advance, Cavendish Imaging will reimburse the amount paid within 3 working days if Cavendish Imaging is unable, for any reason, to perform the services on the day of the appointment. Cavendish Imaging does not agree to pay any party more than the initial amount paid in advance to Cavendish Imaging.

Insured patients:

Even when using medical insurance, patients remain responsible for all services provided by Cavendish Imaging at this and any future appointments and will be liable for any charges not covered by their insurer. It is the patients' responsibility to contact their provider to obtain any authorisations that may be required. Cavendish Imaging will submit invoices to the insurers using these authorisations.

On the day of your visit, you will be required to provide us with your credit/debit card details, for us to be able to debit any excesses or liabilities that were not covered by your insurer. These excesses or liabilities will be debited without prior notice.

Late payments:

Cavendish Imaging is not liable for disputes between patients and insurers, referrers, or third parties responsible for payment. In cases of non-payment within 3 months of service, the patient remains responsible for the balance. Cavendish Imaging reserves the right to pass the collection of any balance to formal collection which may incur charges that will be added to the debt.

I understand payment and billing, and I agree

Signature:

I am completing this form myselfI am completing this form on the patient's behalf. Please state your name and relationship to the patient:

I confirm that the information provided above is true and correct to the best of my knowledge.

Date:
Signature: