Royal Orthopaedic Hospital, Private Patient Care Terms & Conditions
OUR TERMS
1. OUR CONTRACT WITH YOU
1.1 These are the terms and conditions on which we supply fixed price services to you. The Admission Letter and Undertaking to
Pay form is the contract for services between you and us. By signing the Undertaking to Pay form, you agree to the terms of
the contract.
1.2 Please ensure you read these terms carefully. If you have any questions, concerns, or comments, please contact us prior to
admission to discuss. You are responsible for reading and agreeing to these terms prior to consenting to undergo any
treatment.
2. OUR SERVICES
2.1 We will supply the Services to you as set out in the Confirmation of Consultation and/or Admission Letter. This details the
care and treatment that are included in the fixed price hospital fees, and any appointment or admission dates. The Quotation
Letter sets out the fixed price hospital fees and consultant’s and anaesthetists professional fees.
2.2 We will make every effort to provide the Services on the date that we have set out in your Admission Letter. However, we
cannot promise this, and we reserve the right to refuse your admission or appointment for any reason or to cancel or change
the date of your admission or appointment. There may be delays or cancellations for any reason, including but not limited
to an event outside our reasonable control, for operational or technical reasons or because your consultant does not think it
is in your best interest for medical reasons. Where this happens or where we refuse admission, we will try to give as much
notice to you as possible, and any advance payment you have made for Services that have not been provided, will be refunded
to you within 15 working days of notice of the date of cancellation.
2.3 The number of nights stay indicated on your admission and/or Quotation Letter is based on industry standard calculations
for your procedure (CSSD code). The package price covers your admission until you are medically fit for discharge or up to
the number of nights indicated in your admission / quotation letter. We do not offer refunds for patients who are discharged
before the indicated length of stay. A charge may apply if you remain in hospital for longer than the package price covers.
2.4 The decision as to whether you are fit for discharge rests with your consultant. Should you wish to stay in hospital after you
have been declared medically fit for discharge, the hospital’s standard charges will apply, and you will be invoiced separately.
If you discharge yourself against advice of your consultant, no further Services will be provided as part of the fixed price
hospital fees, and no refund will be given if you leave the hospital earlier than expected.
2.5 We will need certain information from you that is necessary for us to provide the Services, and this can be asked for by
anyone involved in your care or treatment including by our staff at the hospital, by your consultant, other medical
professional or in your Admission Letter.
2.6 If you do not, after being asked by us, provide us with this information, or you provide us with incomplete or incorrect
information, we may not be able to provide you with a full range of Services, and that could mean being unable to see you
at our hospital. Of course, if we are unable to provide the Services to you, you do not have to pay for the Services that we
have not provided, but this does not affect your obligation to pay for any Services we have already provided. Any advance
payment you have made for Services, in accordance with the Quotation Letter for Services that have not been provided will
be refunded to you within 15 working days of notice of the cancellation date.
2.7 If you are booked for surgery and choose to cancel prior to your procedure date, payment will be refunded in line with the
terms set out above, but you may be charged for the Services already given to you up to the point of cancellation (e.g. preoperative appointment, imaging scans).
2.8 If you are booked for surgery, payment is required in full prior to the procedure date. If you do not pay us for the services
when the monies are due, we may not provide any remaining services to you with immediate effect until you have paid us
the outstanding amounts.
2.9 We will endeavour, wherever possible to always ensure you are admitted onto the Private Suite for your treatment. On rare
occasions this is not always possible due to factors outside of our control (e.g. lack of beds). If a bed is not available, we will try to accommodate you in a private room on another ward where you will still be able to access the care and amenities you
can expect as a private patient. Should this be the case you will be contacted ahead of your admission by a member of the
team to discuss this.
3. SELF PAY PACKAGE PRICE AND PAYMENT
3.1 Following your consultation with your consultant and us receiving your booking form for admission, you will be asked to go
through the pre-operative assessment clinic (where necessary), which is required to ensure you are medically passed fit for
any procedures. The level of appointment can vary and could consist of either a face-to-face or telephone assessment
depending on the level of treatment that you require and the hospital policies in place at the time. Pre-operative assessment
is an appointment with a nurse in which you will be asked questions about your health and medical history. If following
completion of the pre-operative assessment, we consider that for clinical reasons it is not appropriate to proceed with your
surgery, either at all, or further tests or assessments need to be carried out, or at a different price, we will send you a revised
Admission Letter with a new date for surgery and quotation price letter. If we are not able to continue the surgery at all, we
will advise you of the reasons why.
3.2 If we are still able to offer the surgery, but at a later date (due to the tests or assessments required) we will send you an
Admission Letter with a new date for surgery. We will also confirm the hospital fees for the surgery and other items and
Services, either as a fixed price hospital fee package or, if the procedure is not included in the fixed price hospital fees list or
cannot be covered based on your pre-operative assessment results, an itemised quotation.
3.3 We will detail in your Quotation Letter the fixed price hospital fees for your treatment. Costs incurred that are not included
in the fixed price hospital fees will be charged at the hospital’s standard charges.
3.4 We calculate the fixed price hospital fees based on:
a. Your consultant’s medical advice.
b. The results of any scans and diagnostic tests,
c. The complexity of your care and treatment,
d. The CSSD code (Clinical Coding & Schedule Development group code) provided by your consultant,
e. The results of your pre-operative assessment.
3.5 We will ask you to pay the fixed price hospital fees in full, with the funds having cleared in advance of your admission to the
hospital. We may refuse admission if you have not paid in full. Your rights to a refund on cancellation are set out in clause 14. Details of our payment methods will be included in your Quotation Letter.
3.6 We do not offer the option of flexible pay where the cost of surgery can be split over instalments over a period of time.
Payment is required in full prior to the surgery date.
3.7 Your consultant, who may be a physician, consultant, or anaesthetist, is an independent medical practitioner, and not
employed by us for private practice, may charge you separately for his/her services. Those charges will be set out in the
Quotation Letter. The fixed price hospital fees will not include your consultant’s fees, but we may take payment for their
fees on their behalf. In this event, we are acting as the Consultants’ agent only in collecting those fees; they remain an
independent medical practitioner.
3.8 We are not responsible for the acts and omissions of consultants, anaesthetists, or other independent medical practitioners.
Your consultant and their secretarial staff also do not have authority from the hospital to quote for hospital charges. Any
hospital prices mentioned by them are subject to written confirmation by the hospital.
3.9 We do not accept responsibility for any loss, theft or damage of any personal items or belongings and as such items brought
onto hospital premises are done so at your own risk. As set out in your Admission Letter you are encouraged to remove any
jewellery before surgery, and we therefore recommend leaving valuable items at home.
3.10 Included in your admission and/or appointment letter will be a parking permit. This permit will offer free parking for one
day if it is validated providing you abide by the Trust’s Parking Terms and Conditions displayed by the parking machines and
that the voucher is printed and displayed on the car dashboard with the registration number inserted and the day and month
circled. Please note this permit does not guarantee you a parking space on site and we will be unable to reserve a space for
you ahead of your admission/appointment.
4. INCLUSIONS AND EXCLUSIONS
4.1 What is included?
Unless we have said otherwise, the fixed price hospital fees for your surgery include:
• Any hospital care or treatment, provided it is part of the care and treatment plan devised by your consultant for
you as part of your fixed price hospital fees at the hospital.
• Your consultant’s or other healthcare professional’s operating fee and anaesthetist’s fee while you are an inpatient in the hospital.
• Your pre-operative assessment.
• Your accommodation and meals until you are medically fit for discharge
• Your nursing care while you are in the hospital.
• The hospital’s theatre fees, drugs and dressings while you are in the hospital.
• Any necessary prosthesis (approved by us) where the procedure you will undergo at the hospital requires a
prosthesis.
• Diagnostic imaging, such as x-rays or scans, physiotherapy, pathology, and histology needed while you are an inpatient in the hospital.
• Basic walking aids where clinically required for use in the hospital (such as walking sticks or crutches and
wheelchairs) but not home aids or large items (such as stair lifts).
• Any other treatments if indicated within the Quotation Letter.
• Treatment for any post operative clinical complications.
4.2 What is excluded?
Unless we have said otherwise, the fixed price hospital fees for your surgery exclude:
• Treatment in the High Dependency Unit (HDU)
• Diagnostic tests or services undertaken as part of your consultant’s initial investigation to establish your diagnosis
and subsequent treatment of your condition, and which is undertaken prior to your pre-operative assessment.
These will be invoiced separately.
• The consultant’s or any other healthcare professional’s fee for the initial outpatient consultation. These fees are
invoice separately by the consultant and the hospital does not accept payment for consultations.
• Any care or treatment provided anywhere other than at the hospital, including any NHS care or treatment or any
treatment, diagnostic investigations or care undertaken at a different hospital to the Royal Orthopaedic Hospital.
• Any long-term care or treatment, which is longer than the extent of care indicated at the time of booking.
• Any take home drugs or medication and equipment that is not routinely provided for your procedure.
• Any convalescence, treatment, accommodation, or meals provided by the hospital after you have been passed fit
for discharge.
• Personal costs such as visitors’ meals and other sundry items.
• Ambulance or taxi fees.
• Any costs or fees not specified as included in clause 4.1 or in your Admission Letter.
• Any provision of any of the above will be charged separately to you at the hospital standard charges, and you will
be responsible for payment of those charges.
• Any medical treatment not related or connected with the care and treatment identified at your pre-assessment,
which requires a separate pathway of care, or is not clinically required, whether or not carried out at the hospital,
even if you are not discharged from hospital, is not included in the fixed price hospital fees.
5. NHS TREATMENT
5.1 If you require any NHS treatment and you are not eligible for free at the point of use NHS treatment as stipulated in the
National Health Services (charges to overseas visitors) Regulations 2015 (as amended (the “Overseas Regulations”), you will
be liable to pay any charges for any treatment or care carried out by the NHS, and we shall invoice you to recover any costs
incurred as a result of any NHS treatment in line with the Overseas Regulations.
5.2 If you require any unexpected care in the Royal Orthopaedic Hospital’s high dependency unit you will be transferred as an
NHS patient (where applicable).
6. INSURED PATIENTS
6.1 You agree to pay for your care.
6.2 Whilst you remain responsible for the payment of your care, where you have private medical insurance.
a. You will agree to sign our Undertaking to Pay form, authorising the direct payment of charges to your insurance
company.
b. We will, where possible, process the insurance claim for your care with your insurer, provided you have given
us and your insurer all the information we and your insurer need to do so, including but not limited to, CSSD
procedure code, your policy and pre-authorisation numbers. If this information is incomplete or inaccurate, we
may not be able to process your claim and you will need to pay for your care, as set out in (d.) below.
c. Where we process your insurance claim and your insurer pays us direct, the rate agreed between the Royal
Orthopaedic Hospital and your insurer (rather than the Hospital’s standard rates) will apply to your care.
d. If your insurer fails to settle our invoice (or any part of them) within 60 days of the date of issue, we will assume
that the outstanding amount will not be paid by your insurer, and we will invoice you directly.
e. If we invoice you for your care or any element of it, you agree to pay us the amount invoiced within the time
limits set out therein. If you do not think that we have invoiced you correctly, please let us know as soon as
possible so we can investigate this further.
6.3 It is your responsibility to confirm with your insurer in advance that your care is covered by your insurance policy so
authorisation can be obtained; we cannot obtain any such information on your behalf. It is also your responsibility to ensure
you are authorised for treatment at the Royal Orthopaedic Hospital. Authorisation numbers relating to other venues will not
be accepted and you may be liable to settle the amount owed for your treatment. While you are at the Woodlands Suite,
Royal Orthopaedic Hospital, if you want to check with your insurer whether any aspect of your care is covered by your
insurance policy, you will have access to a telephone so you can contact your insurer. You may be required to obtain
confirmation of cover from your insurer for various aspects of your treatment throughout your pathway. At this point, your
insurer will inform you if you need to pay a shortfall for any aspect of your treatment.
6.4 The Royal Orthopaedic Hospital will not be responsible for any insurer shortfall in cover. We recommend you confirm your
policy limits with your insurer before you undertake your treatment.
6.5 Depending on the policy you have with your insurance company, you may be required to pay an excess. Should this be the
case you can contact our finance department to arrange this. Details of how to do this will be specified in you Admission and
Quotation Letter.
6.6 Your insurer may require access to your medical records in order to validate and approve your treatment. Access also might
be required to allow your insurer to audit the Royal Orthopaedic Hospital’s performance of contract between the Royal
Orthopaedic Hospital and your insurer. Any audit undertaken by your insurer will be for the purposes of validating the
accuracy of the Royal Orthopaedic Hospital’s charges and assessing and assuring the quality of services provided by us.
6.7 Please note that in some cases the care pathway determined by the consultants, nursing staff and other medical professionals
providing your care may not be covered by your insurance policy. This could mean that your insurer may not pay for certain
parts of the care you receive, and you will be required to pay for that part of your care. In particular you should note that
treatment for complications may, in some cases, not be covered by your insurer, and in such cases, you agree to cover the
cost of your care as set out in clause 6.2.
6.8 Please note that your insurance policy may not cover the cost of sundry items or other items such as specialist equipment,
like crutches or wrist braces, or certain medications, or it may only cover part of such costs. You will be required to pay for
any such items not reimbursed by your insurer. If you are unsure as to what items are not covered with your insurance
company, you should contact them ahead of your procedure to clarify this.
6.9 If you pay for your treatment and subsequently seek reimbursement from your insurer, and if no other rate has been
expressly agreed between you and the Royal Orthopaedic Hospital and your insurer, the hospital’s standard rates will apply
to your care.
7. NHS PATIENTS PAYING FOR A PRIVATE ROOM
7.1 If you are an NHS patient but wish to pay for a private room, we will wherever possible endeavour to accommodate you on
the Private Suite during your stay in hospital. Due to the ongoing nature of admissions and discharges it may not be
possible to confirm a room with up to as little as 24-48 hours prior to your admission date. A member of our team will
contact you prior to your day of surgery to inform you if we are able to accommodate you on the Private Suite.
7.2 Prices to stay on the Private Suite are charged at a standard rate. A member of our team will discuss this with you prior to
your admission date so you are aware of the cost of the room.
7.3 As with our self-funding and insured private patients, you will be required to sign out Undertaking to Pay form agreeing to
pay the Services you have received.
7.4 What’s included:
• Private ensuite room on the Woodland’s Suite (includes TV and WIFI)
• A choice of meals from our private patient menu (catering to dietary requirements)
7.5 We will endeavour to honour your booking for as long as you are in hospital. However, on occasions if the bed is needed
for a planned private admission, we reserve the right to cancel your booking and transfer you back to an NHS bed. Should
this happen a member of our team will discuss this with you, and you will only be charged for the number of nights you
have used the service.
7.6 Payment is not required prior to your surgery date. Following discharge, we will be in touch to discuss the total amount for
your stay, and you will be invoiced for that amount. Payment must be made within 30 days.
8. PATIENTS RECIEVEING PRIVATE IMAGING SERVICES
8.1 If you are receiving imaging services (including but not limited to X-Rays, MRI, and CT scans) you will be governed by the
same terms as set out above (i.e. you agree to pay for your care).
8.2 If you are a self-funding patient, where possible you will be provided with the cost of the scan ahead of your appointment
as well as information on how to make payment.
8.3 If you are an insured patient we will, where possible process the fee with your insurer, at the rate agreed with your insurer
and the Royal Orthopaedic Hospital. In order to do so we will require you to provide us with all the information, including
but not limited to type of scan being administered, your policy and pre-authorisation numbers. If your insurer fails to settle
our invoice (or any part of them) within 60 days of the date of issue, we will assume that the outstanding amount will not
be paid by your insurer, and we may invoice you directly.
8.4 You will be required to sign an Undertaking to Pay form on the day of your appointment agreeing to pay for the Services
you have received.
9. INTERNATIONAL PATIENTS
9.1 By signing an Undertaking to Pay Form and agreeing to these terms you confirm that you have the necessary documentation
to enter the UK and that you meet all relevant immigration criteria. You also confirm that you have made adequate
arrangements to pay for your care. The Royal Orthopaedic Hospital may contact the Home Office or UK Border Agency (as
relevant) to obtain necessary clarification on information regarding your visa to enter or remain in the UK in connection with
your care.
9.2 If you stay longer than your expected length of stay (as outlined in your Admission and Quotation Letter) you may be subject
to additional charges for the amount of time you stay in hospital.
9.3 As set out above, in clause 2.3 the length of stay indicated on your Admission and/or Quotation Letter is based on industry
standard calculations for your procedure code (CSSD code). We do not offer refunds for patients who are discharged before
the indicated length of stay. A charge may apply if you remain in hospital for longer than the package price covers.
10. FOLLOW-UP AND COMPLICATIONS
10.1 While we will always try to meet your expectations, we cannot guarantee the result of any procedure, care or treatment,
and it is possible that complications with your treatment or surgery can occur. Your consultant will explain these to you
before your treatment when going through the consenting process.
10.2 The fixed price hospital fees cover the cost of your post-operative care and medical or surgical complications directly related
to your surgery for 6 months following your discharge from the hospital following the procedure to the extent described in
clause 4.1, provided that:
• Such post-operative care and complications are treated at the hospital; and
• You have followed the advice of your consultant involved in your care or treatment at the hospital. The decision
as to whether a complication is related to the procedure rests with your consultant.
11. CHANGES TO THESE TERMS
11.1 We may change these terms at any time, including, for example:
a. Where we reasonably consider it will make it easier to understand; or
b. Because of changes to the law, codes of practice or the way in which we are regulated.
c. To cover a development or change in the services that we provide.
11.2 If we have to change these terms under clause 11.1, the new terms will only apply to any new care or treatment that you
may receive and will not apply to any care or treatment that you may be part through or currently receiving as part of the
fixed price hospital fees when the change of these terms is made.
11.3 If you wish to end any care or treatment before it is completed, you may do so and your rights to do so are set out in
clause 14.
12. IF THERE IS A PROBLEM WITH THE SERVICES PROVIDED
12.1 If there is any problem with the Services we provide, please contact us, and tell us as soon as reasonably possible, and we
will investigate the problem under our complaints procedure and try to repair or fix the problem as soon as we can. Please
ask a member of staff at the hospital for a leaflet about our complaint’s procedure. Your right to a refund in such
circumstances will be decided on a case-by-case basis.
12.2You have legal rights in relation to services not carried out with reasonable skill and care, or if the materials we use are faulty
or not as described. Nothing in these terms will affect these legal rights.
12.3 If the hospital fails to comply with the contract, the hospital is responsible for loss and damage you suffer that is a foreseeable
result of the hospital breaching this contract or the hospital’s failing to use reasonable care and skill, but the hospital is not
responsible for any loss or damage that is not foreseeable. Loss or damage is foreseeable if it is either obvious that it will
happen at the time this contract was made, or if you and the hospital both knew it might happen, for example, if you discussed
it with the hospital prior to the date of the provision of Services.
12.4 The hospital does not exclude or limit in any way our liability to you where it would be unlawful to do so. This includes
liability death or personal injury caused by our negligence of the hospital’s employees, agents, or subcontractors; for fraud
or fraudulent misrepresentation; for breach of your legal rights in relation to the Services included under our contract.
13. EVENTS OUTSIDE OUR CONTROL
13.1 We will not be liable or responsible for any failure to perform, or delay in performance of, any of our obligations under these
Terms that is caused by an event outside our reasonable control, including but not limited to Epidemics or Pandemics, Natural
disasters, strikes etc.
13.2 If any event outside our reasonable control takes place that affects the performance of our obligations under these terms,
we will contact you as soon as reasonably possible to notify you, and our obligations under these terms will be suspended
and the time for performance of our obligations will be extended for the duration of the event outside our reasonable control.
13.3 You may cancel the contract if an event outside our reasonable control takes place, and you no longer wish us to provide
the Services. Please see your cancellation rights under clause 14.
14. YOUR RIGHTS TO CANCEL AND APPLICABLE REFUND
14.1 If you decide not to go ahead with the procedure as part of your fixed price hospital fees, you may contact us at any time
to cancel.
14.2 If your procedure is carried out, you shall not be entitled to a refund. If you discharge yourself early following your
procedure, either deciding to yourself or being medically fit to do so, you will not be entitled to any refund of monies.
14.3 Depending on when you inform us of your wish to cancel, the following rate of refund deduction shall apply:
• Cancellation prior to pre-assessment with no other scans or Services received- 100% refund.
• Cancellation after pre-assessment with no other scans or Services received- 100% refund minus £350.
• Cancellation after pre-assessment with other scans or Services received- 100% refund minus the costs of scans or
services received based on current prices
• Cancelation after custom made prosthesis is ordered- will incur full cost of prostheses in addition to any of the
other deductions listed above plus 20% administration fee.
14.4We will refund any advance payment made by you or on your behalf for Services that we have not yet provided to you. Any
such refund will be made BACS transfer only to the cardholder or person who made the original payment, within 15 working
days of notice of the date of cancellation. Please note we do not make refunds in cash.
14.5 You are responsible for complying with all the terms of our contract, including, but not limited to, timely payment of all fees
due and payable prior to admission.
15. OUR RIGHTS TO CANCEL AND APPLICABLE REFUND
15.1We may have to cancel any appointment or admission date or any care or treatment to you before it is due to start for
any reason, including, for example, due to unavailability of key personnel or key materials without which we cannot provide
your care or treatment or because of an event outside our reasonable control. We will promptly contact you if this
happens. We will always try to rearrange any appointment or admission dates with you. If we are not able to find any
suitable alternative dates, and instead we have to cancel the provision of any part of the fixed price hospital fees to you, and
payment in advance has been made by you, we will refund these amounts by BACS transfer only to the cardholder or
person who made the original payment, within 15 working days of notice of the date of cancellations. Please note we do not
make refunds in cash.
15.2 If your consultant cancels your treatment because they consider it is not in your best interests for medical reasons, and
(a)you have already paid for your Self-Pay Package, we will refund your payment. Note that you will not be required
to pay for any care included in your Self Pay-Package that you received up until the point of cancellation; or
(b) you have already paid for other non-packaged self pay Services, we will refund your payment. Note that you will
not be required to pay for any care that you received up until the point of cancellation.
15.3We have the right to cancel your admission at any time if you do not pay us when you are supposed to. Your rights to a
refund on cancellation are set out in clause 14. You must pay each invoice in cleared funds within 30 calendar days of the
date of invoice, and payments are accepted via BACS or over the telephone.
16. INFORMATION ABOUT US AND HOW TO CONTACT US
16.1 The Royal Orthopaedic Hospital, Woodlands Private Suite is based on the Woodlands Suite of the Royal Orthopaedic
Hospital. If you have any questions or you wish to contact us (for example, to cancel the contract) you can contact us by
telephone or email on the following contact details:
• Bookings/forthcoming admission/payment queries - Telephone: 0121 685 4010.
• Bookings/forthcoming admission/payment queries - Email:
• Quotation queries - Telephone: 0121 685 4010
• Clinical Service Manager – Telephone: 0121 685 4010.
• Cashiers’ office- 0121 685 4326
• To speak to the nursing team on the Woodlands Suite ward- 0121 685 4112
• If your query is about your treatment, please contact your consultant’s private practice secretary.
17. INFORMATION ABOUT US AND HOW TO CONTACT US
17.1 It is important that you keep us updated of any changes in your contact details.
17.2 We are a company registered in the England and Wales. Our NHS organisation code if RRJ. Our registered address is:
The Royal Orthopaedic Hospital NHS Foundation Trust
Bristol Road South
Northfield
Birmingham
B31 2AP
United Kingdom
17.3 The entity responsible for your care (The Royal Orthopaedic Hospital) will be set out in your Admission Letter. If you have
any questions or if you have any complaints, or wish to contact us, you can contact us by telephoning our team on 0121 685
4010.
18. DEFINITIONS
When we use the words “we”, “our” “us” or “hospital” in these Terms, we the Royal Orthopaedic Hospital Woodlands Private
Suite or a member of the Royal Orthopaedic Hospital Woodlands Private Suite.
18.1 When we use the words “writing” or “written” in these Terms, this will include email and postal correspondence.
18.2When the following words with capital letters are used in these Terms, this is what we mean:
Admission Letter: The letter that we send to you detailing the care and treatment. The letter will include confirmation of
the date of your procedure.
Confirmation of consultation letter: The letter we send you detailing your consultation appointment with a consultant.
Package Price: The price that you pay for the self-pay package and which we set out where relevant in the Admission
Letter.
Quotation Letter: The letter that we send to you (where applicable) detailing either the Package Price to be provided to you
under the self-pay package or an estimate for costs where the treatment is not included within the self-pay package.
Self-Pay Package: the care, treatment, or procedures to be carried out as a private patient at the hospital, to which a Package
Price applies as detailed in your Admission Letter where applicable to you.
Services: The services that we are providing to you as set in your appointment and/or Admission Letter.
Terms: the terms and conditions set out in this document.
Undertaking to pay form: The form signed by you prior to your admission/procedure to hospital
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