If you would like to become part of our network, please complete and submit the form below.

On completion of this form, please send a current pricelist and a copy of applicable licences to:
AXA Global Healthcare (UK) Limited, International House, Forest Road, Tunbridge Wells TN2 5FE, UK.
Fax +44 1892 503189 – Email GlobalNetworkmanagement.health@axa.com

Please make sure you complete all fields marked *.

Provider Information

Yes No

Key contacts

Insurance Manager

Finance Billing Manager

Guarantee of Payment contact

Provider bank details

Complimentary information

Yes No

Facility statistics

Hospital list of specialities and facilities

Yes No