I confirm that, to the best of my knowledge and belief, the information I have given on this form is true and correct. I consent to all relevant medical records and images being stored digitally by ent4kids until I notify you otherwise. I hereby undertake to pay ent4kids for services & materials relating to my/my child's treatment as a private patient, including any circumstances where medical insurance proves not to cover the specific course of treatment, in which case I agree to settle my account upon receipt of invoice. I consent to my details being shared with a debt collection agency should I fail to settle the account within the payment terms. Should it be necessary to refer to a third party medical provider for a further opinion/further diagnostic testing, I consent to the sharing of my personal data to facilitate this referral. Should your medical insurance company require a diagnosis, or medical report for payment purposes, I consent to the sharing of my personal data to facilitate this claim. Please note that Mr Daya has a financial interest in ent4kids.

Patient Forms