Online Appointment

Name*

Email*

Phone*

I am a...*

New Client
Existing Client

Existing client

Date of Birth

Appointment Type

Preferred Clinic

Preferred Date

Preferred Time

Comments

*

I have read and accept the companies terms and conditions for booking

*

I am aware of and agree to the 24 hour cancellation policy

New client

Preferred payment method?

I am paying myself
Private medical insurance
I have been referred by a third party e.g employer, solicitor

Date of Birth*

First Line of Address*

Postcode*

Insurer

Policy No.

Authorisation Code

Sessions Authorised

Excess

Preferred Clinic

Preferred Date

Preferred Time

Comments

*

I have read and accept the companies terms and conditions for booking

*

I am aware of and agree to the 24 hour cancellation policy

*

I will cover any unsettled appointment fees in the event that my claim is not settled by my insurer within 60 days

Date of Birth*

First Line of Address*

Postcode*

Referring Company

Preferred Clinic

Preferred Date

Preferred Time

Comments

*

I have read and accept the companies terms and conditions for booking

*

I am aware of and agree to the 24 hour cancellation policy

*

I will cover any unsettled appointment fees in the event that my claim is not settled by the referring company within 60 days

Date of Birth*

First Line of Address*

Postcode*

Appointment Type

Preferred Clinic

Preferred Date

Preferred Time

Comments

*

I have read and accept the companies terms and conditions for booking

*

I am aware of and agree to the 24 hour cancellation policy

Online Appointment

Existing client

New client

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