Parent / Carer Information
*
First Name
Last Name
Parent Email
*
Phone Number (Parent / Carer)
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Child's Name
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First Name
Last Name
Date of Birth
*
MM
DD
YYYY
I confirm that I have parental responsibility for the child named above
*
Summary of medical concern / Reason for appointment
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Please summarise why you are bringing your child to see us at the Bristol Paediatric Clinic. e.g. What is your medical concern? Is there anything specific you are hoping for us to do?
Please provide as much information as possible so we can find the most suitable BPC clinician for you.
GP Information
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Is your child (are you) registered with a GP?
GP Information
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What is the the name and address of the GP Practice (and the name of the GP) with whom your child (you) is registered?
GP Information Sharing
*
Do you consent to us sharing a summary letter of your appointment with your GP?
(This kind of information sharing is really important for children and unfortunately the Bristol Paediatric Clinic won't see children where this consent has not been given)
Medical Insurance Information
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Do you have private medical insurance that you are intending to use to pay for your care with the Bristol Paediatric Clinic?
Medical History
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Does your child have any diagnosed medical conditions?
Medications
*
Does your child use any medications regularly?
Allergies
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Does your child have any allergies to any medications or any other allergies?
Your Child's Visit to Bristol Paediatric Clinic
Is there anything we can do to make your visit better or more comfortable when you come to see us? Specific adjustments you would like us to try to make (e.g. vision or hearing issues)? Cartoons we can have ready for your child to watch to make them feel more comfortable (for example)? We can't guarantee it, but we'll certainly try our best. We are looking forward to meeting you.
T&Cs Agreement
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The Terms & Condtions set out below are important and contain information about our cancellation policy, cancellation fees and other payment and fees information.
I have read and agree to the terms and conditions set out below
Terms and Conditions (T&Cs)
1. About our services:
Bristol Paediatric Clinic provides comprehensive paediatric care, including (but not limited to): Gastro-oesophageal reflux; Crying; Colic; Feeding difficulties; Jaundice; Constipation; Sleep issues; Allergies; Birth marks and Rashes; Concerns about head shape; Faltering growth; Routine 6 Week Examinations and Well-Baby Check-ups; Coeliac disease; Abdominal pain; Vomiting and Diarrhoea; Coughing and Recurrent Infections; Asthma and Wheezing; Fever; Tonsillitis; Rashes; Eczema; Bladder problems; Neurological concerns; Anaemia; Well-Child Check-ups; Headaches; Constipation; Bladder problems; Anaemia; Early & Delayed puberty; Disordered eating; Well Teen Check-ups.
2. Fees and payment information
• New appointment (45 minutes) - £260
• Follow-up appointment (30 minutes) - £190
• Virtual follow-up appointment (30 minutes) - £190
• Missed appointment fee - £50
• Blood test - The prices of blood tests are variable and are charged in addition to the appointment fee. There is also a £75 phlebotomy and medical admin fee.
• Skin prick tests - £100 (for up to 10), £150 (for 11-20)
• Spirometry – £60
• Private Prescriptions (in appointment) – Free (but subject to a dispensing fee from your Pharmacist)
We accept the following payment methods: Debit cards, credit cards, online, bank transfer, direct debit and certain insurers.
BPC works in partnership with Bill Medical to collect and process payments. Insurance companies will be billed directly by Bill Medical on behalf of BPC. Bill Medical's contact details are as follows:
Website: www.bill-medical.co.uk
Tel: 01494 416411
You are responsible for paying all fees associated with your child's care, regardless of insurance coverage. This may require you to self-pay if there is a difference between what an insurance policy covers and BPC fees.
Failure to make payment within two weeks of the due date may result in you account being referred to a debt collection agency. This could lead to additional charges and negatively impact your credit rating.
Our fees are subject to change. You will be notified of any changes in advance.
3. Information about BPC Consultant Directors
· Dr Dan Magnus; Consultant Paediatrician; Consultant in Paediatric Emergency Medicine; NHS practice: Bristol Royal Hospital for Children
· Dr Nick Sargant; Consultant Paediatrician with a special interest in Paediatric Allergy; NHS practice: Bristol Royal Hospital for Children and the Royal United Hospital, Bath
4. Availability of information
Further information about our services, fees, and policies is available upon request. Please do not hesitate to ask a member of our staff if you have any questions.
5. Right to complain
If you are unhappy with any aspect of our services, please contact us directly so we can address your concerns. You can either email or telephone us using the following contact information: admin@bristolpaediatric.com; 01172130685.
6. Confidentiality
We are committed to maintaining the confidentiality of your child's medical records. We will only disclose information as required by law or with your informed consent. It is BPC standard practice to securely share a summary of every consultation with the child’s GP.
7. Cancellations
Please provide 48 hours' notice if you need to cancel or reschedule an appointment. A cancellation fee of £50 will be charged for late cancellations or missed appointments.
8. Contact information
Bristol Paediatric Clinic, Litfield House Medical Centre, Litfield Place, Clifton Down, Bristol, BS8 3LS.
Website: www.bristolpaediatrics.com
Email address: admin@bristolpaediatrics
BPC telephone: 01172130685
Litfield House telephone: 01179731323
