PATIENT REGISTRATION FORM

Contact details

CLINICAL DETAILS


Available time - Thursday 01pm - 05pm & Friday 10am - 5pm

FINANCIAL DETAILS

Patient undertaking:

Cancellation Policy

Dr Habibi’s Clinic operates a 24 hour cancelation policy. Appointments cancelled within 24 hours, or non-attendance, will incur a cost of 50% of the consultation fee.

Please arrive at least 15 minutes prior to your appointment time to allow for registration and Nursing observations to be done.

Dr Habibi’s clinic allocates 1 hour for your first consultation. Please inform us if you’re going to be delayed, please call Tel: 07939 807767.

However, late attendance by more than 30 minutes may result in having to reschedule your appointment and incur additional costs.

All patients/ patient payor / representative

I/we undertake to pay all services rendered and items supplied to me/the patient in accordance with the hospital/consultant’s charges applicable at the time of treatment.

I acknowledge that I remain liable for such payment, whether or not I/the patient have/has medical insurance or third party sponsorship in respect of some or all of the services provided and items supplied. If following discharge there is a shortfall or excess due to the hospital/consultant, I accept that I/patient will be invoiced for this sum and I hereby agree to pay this direct to the consultant.

How we use your medical records

Important information for patients

  • This practice handles medical records in-line with laws on data protection and confidentiality.
  • We share medical records with those who are involved in providing you with care and treatment.
  • In some circumstances we will also share medical records for medical research, for example to find out more about why people get ill.
  • We share information when the law requires us to do so, for example, to prevent infectious diseases from spreading or to check the care being provided to you is safe.
  • You have the right to be given a copy of your medical record.
  • You have the right to object to your medical records being shared with those who provide you with care.
  • You have the right to object to your information being used for medical research and to plan health services.
  • You have the right to have any mistakes corrected and to complain to the Information Commissioner’s Office. Please see the practice privacy notice on the website or speak to a member of staff for more information about your rights.
Professor Parviz Habibi Available At

Harley Street Private Practice

4th Floor Room 10,
84 Harley St, Marylebone,
London W1G 7HW, UK

The Harley Street Clinic

35 Weymouth Street
London
W1G 8BJ

The New Malden Diagnostic Centre

171 Clarence Avenue
Surrey
KT3 3TX

The Portland Hospital Out Patient Centre

205-209 Great Portland
Street London
W1W 5AH