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Name
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Last
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I am a...
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New Client
Existing Client
Existing client
Date of Birth
DD slash MM slash YYYY
Appointment Type
Appointment Type
Physiotherapy
Sports Massage
Preferred Clinic
Preferred Clinic
Camden
St Pancras
Westminster
Old Broad Street
Cambridge (Woodlands Surgery)
Cambridge (Bridge Street)
Bushey
Old Street
Hillingdon
East Sheen
Richmond
Wimbledon Park
Deansgate, Manchester
Salford
Handforth, Manchester
Golders Green
London Bridge
East Finchley
Birmingham Central
Epping
Preferred Date
DD slash MM slash YYYY
Preferred Time
Preferred Time
Morning
Afternoon
Evening
Comments
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I have read and accept the companies terms and conditions for booking
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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
*
DD slash MM slash YYYY
First Line of Address
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Insurer
Insurer
AXA
BUPA
AVIVA
Vitality (formerly Pru Health)
Cigna
CS Healthcare
WPA
Simply Health
Allianz
AIU Insurance Company
Other (please add in comments)
Policy No.
Authorisation Code
Sessions Authorised
Excess
Preferred Clinic
Preferred Clinic
Ashby
Brigg
Grimsby
Cambridge - Bridge Street
Cambridge - Woodlands
Manchester - Deansgate
Birmingham Central
Epping
Bushey
Barbican
Camden
Canary Wharf
Bank
Farringdon
Chiswick
Clapham
Harley Street
Holborn
Liverpool Street
London Bridge
Mayfair
Old Street
Paddington
Richmond
Kings Cross
St Pauls
London Victoria
Westminster
Preferred Date
DD slash MM slash YYYY
Preferred Time
Preferred Time
Morning
Afternoon
Evening
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
*
DD slash MM slash YYYY
First Line of Address
*
Postcode
*
Referring Company
Preferred Clinic
Preferred Clinic
Camden
St Pancras
Westminster
Old Broad Street
Cambridge (Woodlands Surgery)
Cambridge (Bridge Street)
Bushey
Old Street
Hillingdon
East Sheen
Richmond
Wimbledon Park
Deansgate, Manchester
Salford
Handforth, Manchester
Golders Green
London Bridge
East Finchley
Birmingham Central
Epping
Preferred Date
DD slash MM slash YYYY
Preferred Time
Preferred Time
Morning
Afternoon
Evening
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
*
DD slash MM slash YYYY
First Line of Address
*
Postcode
*
Appointment Type
Appointment Type
Physiotherapy
Sports Massage
Workplace Assessment
Preferred Clinic
Preferred Clinic
Camden
St Pancras
Westminster
Old Broad Street
Cambridge (Woodlands Surgery)
Cambridge (Bridge Street)
Bushey
Old Street
Hillingdon
East Sheen
Richmond
Wimbledon Park
Deansgate, Manchester
Salford
Handforth, Manchester
Golders Green
London Bridge
East Finchley
Birmingham Central
Epping
Preferred Date
DD slash MM slash YYYY
Preferred Time
Preferred Time
Morning
Afternoon
Evening
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
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