To be completed by medical professionals only.
LENGTH OF STAY*:WIWODAYCASEINPATIENT
PAYMENT TYPE*SELF-FUNDINGINSURANCEEMBASSYSELF PAY FIXED PRICE PACKAGEOTHER
PRICE CONFIRMED WITH BOOKINGS TEAM:
Please SelectYESNO
C-ARM/X-RAY/IMAGE-INTENSIFIER NEEDED:
Please selectNOYES
Micro Air Handpiece requirement*:YESNO
Have you attached details of patients past medical and medication history?*:YESNO
Upload any patient supporting documents
FOR OFFICE USE:
Completed By:
* It is mandatory to supply this information prior to admission
