Registration Form - Shoulder, Elbow, Hand, Wrist Surgeons Manchester

Thank you for contacting us and arranging a consultation at The Arm Clinic. We hope that we can make the experience as stress free as possible. In order to try and help, in what can be a very stressful time, we will explain and offer you all of the alternatives and allow you to make the decisions regarding YOUR body and YOUR treatment.
Name of consultant*
- Prof Len Funk (Shoulder)
- Mr Mike Walton (Shoulder)
- Prof Adam Watts (Elbow, Hand & Wrist)
- I can't remember my consultant's name
How did you hear about us?*
First Name*
Last Name*
Email Address*
Date of Birth*

Payment details
Are you funding this treatment yourself (Self Pay) or do you have private medial insurance cover (insured).
Finance*
- Insurance
- Self Paying
Insurance Company Name
Policy Number
Authorisation Number

COVID
Have you or someone in your household got any of the below symptoms:
- a high temperature
- a new continuous cough
- a loss of, or change in, your normal sense of taste or smell
Have you or someone in your household been told you have confirmed COVID-19 in the last 14 days?*
- Yes
- No
Have you been told you have been in contact with someone who has confirmed COVID19 in the last 14 days?*
- Yes
- No
Have you travelled outside the UK in the last 14 days?*
- Yes
- No
*not including countries specified by the government as exempt from isolation requirements
Any other comments:

Signature and authorisation
I guarantee payment for all services rendered within 28 days of being invoiced. The signature below confirms all the information provided herein is true and accurate. I understand that my email address may be used to send/request information or used for research purposes by or a member of the team but the addresses will NOT be passed onto any outside agency for any marketing purposes. By completing this form, professional athletes, are confirming that they are happy for the invoices regarding this and all future treatment(s) to be sent direct to their club or the club's agent as required but understand that payment of fees is ultimately their responsibility.
Signatory for financial responsibility*
- I am the patient
- I am a guardian / act on behalf of the patient
First Name (Guardian / representative)
Last Name (Guardian / representative)
Terms and Conditions*
- I have a read, understood and agree to the terms and conditions here.
Signature*

Your Details