Appointment request form

Reason for the appointment *

Child's Full Name *

Gender *

Male
Female

Date of Birth *

Home Address *

Address Line 1

City

State / Province / Region

Zip / Postal Code

Country

GP Details *

First Name (Parent 1) *

Email (Parent 1) *

Last Name (Parent 1) *

Phone (Parent 1) *

First Name (Parent 2) *

Email (Parent 2) *

Last Name (Parent 2) *

Phone (Parent 2) *

Are you paying for your child or via insurance? *

Self-pay
Insurance

WE TAKE PAYMENT AT THE TIME OF BOOKING £350 - WE ACCEPT ALL MAJOR CREDIT/DEBIT CARDS AND AMEX

Insurance company

BUPA UK
AXA PPP UK
Other
International Insurance

International patients must self-pay, we will issue you with a receipt and medical report to claim back from your own insurance company. Please choose Self-pay

Insurance company name (International insurance companies not accepted)

Membership/Policy number

Authorisation code

GP referral letter

Drop your file here or click here to upload You can upload up to 1 files.

We cannot book in without a referral letter

Please read the Fee Advice Notification below, answer the questions and sign at the bottom of this form.

Starlight Paediatrics Ltd

Dr Ahmed F Massoud, Consultant Paediatrician & Endocrinologist
Dr Tim Wickham, Consultant Paediatrician & Neonatologist
Dr Muriel Meso, Consultant Paediatrician, Endocrinologist & Diabetologist

Fee Advice Notification (as of 1st October 2026)

Payment of all fees relating to consultations with Dr Massoud, Dr Wickham or Dr Meso, whether outpatient or inpatient, first consultation or follow-up, in-person or remote, is entirely the responsibility of the patient’s parents/guardians. Parents/guardians are therefore liable for settlement of fees, complete or partial, that are not covered by their child’s Private Medical Insurer (PMI), irrespective of the reason for non-coverage.

PRIVATE MEDICAL INSURANCE

Most Private Health Insurers (PMIs), in particular BUPA and AXA Health, stipulate that the patient has seen his/her General Practitioner (GP) ahead of the consultation with the specialist and that a referral letter from the GP is available at the time of the consultation. Please confirm:

The patient has seen the GP for the current problem *

Yes
No
Not Applicable

A referral letter from the GP is available *

Yes
No
Not applicable

Pre-authorization by PMI has been obtained *

Pre-authorization code *

FEES

These apply to self-pay patients. Fees charged to PMIs may differ. Fees do not include any hospital fees or cost of investigations/treatment/vaccines. Most PMIs do not cover consultations for general check-ups and for vaccine administration.

New patient consultation (outpatient or in-patient) up to 30 minutes	£350
Existing patient consultation for a new medical problem up to 30 minutes	£350
Extended consultation for complex medical problems (up to one hour)	£600**
Follow-up consultation	£250
Diabetic Consultations (1 hour) (Dr Meso)	£600**
In-patient medical care	£180 per day (or part of)
Minor day-case dynamic endocrine investigation	£250**
Bone age assessment	£100**
Email advice	£100**
Additional medical reports outside clinic visits	£100**
Additional referral letters outside clinic visits	£100**
Repeat prescriptions outside clinic visits	£50**
Completion of Claim Forms/Camp Forms outside clinic visits	£50 - £100
Home visits/overseas visits	By Special Arrangement**
Review of medical reports for second opinion	By Special Arrangement**

** These services are NOT covered by PMI and must be self-funded.

ACKNOWLEDGEMENT AND CONSENT

I confirm that I have read the above. I accept liability for the Doctor’s fees if self-funded or in case of complete or partial non-payment of fees by my child’s PMI.

I hereby give consent to releasing information to the relevant PMI about my child’s diagnosis/purpose of today’s consultation. As a matter of routine, your child’s medical reports will be sent to his/her General Practitioner, NHS and/or private.

Acknowledgement and consent *

I have read and agree to the Fee Advice Notification and the Acknowledgement and Consent above

Name *

Signature *

Date *

+44 (0) 20 8426 4514

The Portland Hospital Consulting Suite

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