Appointment booking questionnaire

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In order to proceed with confirming your appointment, please complete the form below, providing all available
information. This includes a section regarding your recent activity which will allow us to assess your level of risk
for coronavirus infection before you attend our centre.

We use and process your personal information to provide the services you are referred for. We also use and
process your personal information to comply with our legal obligations to maintain clinical records and to
maintain information security arrangements of our online platform for clinicians. Your personal data will also be
processed for purposes associated with billing your account and record keeping based on our legal obligations
and contractual rights.

If you would like to know more about how we handle your data, please refer to Cavendish Imaging
Patients Privacy Notice.



The payment will be settled by (required)

If insurance:

If third party:

Standard Terms & Conditions:

Cavendish Imaging services and products aim to assist healthcare professionals with diagnosis and treatment
planning. Cavendish Imaging is not providing and is not responsible for providing any clinical treatment.

Cavendish Imaging endeavours to provide the very highest quality results, however Cavendish Imaging will not
accept any liability for incorrect or incomplete information on the referral form or inappropriate or inadequate
patient preparation which may compromise the value of the final results.

Cavendish Imaging endeavours to dispatch the images to the referrer and/or the patient in a timely manner,
however e.g. equipment malfunction may introduce delays. Cavendish Imaging reserves the right not to accept
referrals in such cases. Also, Cavendish Imaging cannot guarantee when radiology reports and data conversions
will be available to the referrers unless the timelines are explicitly agreed in advance. Cavendish Imaging must be
notified a full working day in advance if a particular service is required urgently.

Payment and Billing:

Patients who are self-paying for the services that Cavendish Imaging provides, will settle their accounts prior to
their visit, on the day of their visit at the latest. If not, Cavendish Imaging reserves the right not to proceed with
the services. If the services are provided, delay in the processing of the order or the delivery of the complete
service may occur. In the event of patients having paid for the services in advance, Cavendish Imaging will
reimburse the amount paid within 3 working days if Cavendish Imaging is unable, for any reason, to perform
the services on the day of the appointment. Cavendish Imaging does not agree to pay any party more than the
initial amount paid in advance to Cavendish Imaging.

Patients who are not self-paying for the services that Cavendish Imaging provides, will have the invoice for the
services sent to their insurer/referrer/third party, providing adequate documentation is given to us.

Cavendish Imaging cannot accept any liability for any disagreement between patients and their insurer,
referrer, or third party providing payment to Cavendish Imaging on their behalf. In the event of non-payment to
Cavendish Imaging, within 2 months of the delivery of the service, the patient is ultimately responsible for
settling the invoice (does not apply to NHS-funded referrals).

Cavendish Imaging is registered with most UK insurance companies. If your insurance covers the whole
examination, you will not need to pay anything on the day of your examination as we will claim these costs from
your insurance directly. You just need to bring your insurance membership and authorisation number
specific to the imaging visit.

Radiation exposure and benefits:

Patients wishing to know more about the impact of the radiation used during the imaging procedure can refer to
the Exposure Information leaflet. Please email us if you have concerns that you would like to discuss prior to your appointment.

Covid-specific questionnaire:

Do you have a new, continuous cough?Do you have a high temperature (37.8C or over)?Does anyone in your household have a new, continuous cough or a high temperature?If you or anyone in your household has tested positive for coronavirus, are you still in the self/householdisolation period?None of the above apply to me

Coronavirus advice is available on the government website.

Additional visitors:

Only one carer, interpreter or legal guardian is permitted to attend our patients’ appointment in order to
support them. Please do not attend accompanied by non-essential visitors.

Signature:

I am completing this form myselfI am completing this form on the patient's behalf. Please state your name and relationship to the patient: