Please enter your details, as they appear on your passport (e.g. Joseph Jason Bloggs instead of Joe Bloggs).

By completing this form you (the patient) consent to being contacted by Surgery Now.

A copy of your medical data will be securely stored by Surgery Now and this form is to record your consent being given.

If you wish to withdraw this consent at any point, please contact us.

Click here to see Zed Doctor Platform info

Click here to see Privacy Policy

Click here to see Terms of Use

Private Patient Form
  1. I consent to allow Surgery Now to share Records and Data with our hospitals in the Surgery Now network of hospitals.
  2. I consent to have a Zed account created so that my medical images and documents can be shared with the receiving hospitals and Surgery Now for 12 months. More information about our policy is located here
  3. I have read and agree to the Privacy Policy and Terms of Use 
  4. I consent to allow Surgery Now to contact me by phone, email and SMS.
  5. I consent to allow Surgery Now to discuss claim information with your insurance provider.