The Manchester Pain Clinic: Patient Registration Form

Patient Consultation Registration Form

Please complete this form to register your details for a consultation.
Consultant details
Name of consultant
How did you first hear about The Manchester Pain Clinic?
If answered 'other' to the above, please specify.
- Personal Details
- Full Name
  
  First NameMiddle NameLast Name
- Date of birth
  
  DayMonthYear
- Current Address
  
  Street Address
  
  Street Address Line 2
  
  Town/CityCounty
  
  Postcode
- Email Address
- Home telephone number
  Format: 00000 000 000.
- Mobile telephone number
  Format: 00000 000 000.
- Finance
  Private medical insurance / self-pay
- Insurance provider name
- Insurance policy number
- Insurance authorisation number
- Name of GP
- GP address
- GP postcode
- Name of Physiotherapist
- Physiotherapist address
- Physiotherapist postcode
- Affected area
  Which part of your body is in pain?
- Please supply a brief history of the problem
- Recommended/referred from
- Previous investigations and/or treatments for this problem?
- Have you undergone any previous scans or x-rays for this problem?
- If answered 'yes' to the above, please provide details of where these were done.
- Please provide details of the date when these were done.
- Have you seen a medical limb consultant about this problem?
- Please provide details of any medications you are taking or have previously take for this problem.
- Please provide details of previous surgery you have undergone for this problem.
- Declaration
  
  By submitting this form I declare that the information given in this form is complete and accurate to the best of my knowledge and that I am the patient and am responsible for paying for treatment.
- Terms & Conditions: I am the patient and have a read, understood and agree to the terms and conditions.
- Please upload any further supporting medical information you feel necessary if not already detailed above.
  
  Cancelof
- Signature
- Attach Documents
  
  Please upload any relevant documents to be included with your PDF submission.
  Cancelof
- Registration form submission date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Should be Empty:

Patient Consultation Registration Form

Consultant details

Personal Details

Declaration