Pre-Signing Fee Agreement


 

Referral Details

Referring Sports Club:  

Club Address:  

Email address (to send invoice) if known:  

Player details (Please complete this form in block capitals)

 

Name of Player:  

Date of Birth:

Name of parent/guardian if the patient is under 18 years of age:  

Tests Carried Out (please tick)

ECG

Urine Test

Blood Test

 

 

Spirometry

 

Echocardiogram (Nuffield/Spire)

OCT Test (Optical Coherence Tomography)

 

 

MRI (Number of Areas Scanned):

Price: £ 

Visual Fields Tests

 

Orthopedic Surgeon (Mr Bollen at the Spire)

 

Additional Charges:
 

Price
£ 

TOTAL PRICE
(To be invoiced to club)

£  

 

Terms & Conditions

Additional Comments

 

  1. I am signing to confirm that I will be receiving the above treatments or tests and that I understand that an invoice will be sent to the named sports club for settlement of payment.

  2. I also understand and agree that the fee may increase in the event that further treatments are required to be carried out by LivingCare Health Services.

  3. LivingCare Health Services shall process your personal data in accordance with the obligations set out under the Data Protection Act 2018 which shall apply to these terms and conditions.

  4. LivingCare Health Services accepts no responsibility for personal belongings including damage to any mode of transport when visiting the LivingCare Health Services facility.

  5. I consent LivingCare Imaging to send a medical report of findings back to original referrer via paper copy and secure e-mail.

  6. I understand I may receive digital images of my scan and take responsibility of this data. You will be asked to sign to confirm receipt of any such media and by doing so, accept full responsibility for it’s safe maintenance.

  7. I understand if a 3rd party (inc. private medical insurer) has agreed to pay the above fee, i may be liable for the full cost should they refuse to.

  8. I consent to the examination.

I have read and agree to the terms and conditions set out above. I confirm that the details I have provided are correct and that I have been advised by the person who referred me about the service to be provided. I hereby give my consent to LivingCare Health Services to provide the service.

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Signature Certificate
Document name: Pre-Signing Fee Agreement
lock iconUnique Document ID: 1ab2cfb212c4c4e243996370b0b310dfbf38d039
Timestamp Audit
8 July 2022 2:10 pm BSTPre-Signing Fee Agreement Uploaded by Henry Aspden - [email protected] IP 217.168.249.171