Appointment request form

Appointment Request

Dr. Ahmed Massoud, Dr. Tim Wickham, Dr. Muriel Meso

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 £250 (£350 FOR DR MASSOUD) - WE ACCEPT ALL MAJOR CREDIT/DEBIT CARDS AND AMEX

Insurance company

BUPA UK
AXA PPP UK
International Insurance
Other

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

+44 (0) 20 8426 4514

The Portland Hospital Consulting Suite

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Appointment request form