Booking

Please note that all fields with a (*) symbol are mandatory.

PATIENTS DETAILS

Please complete this form in full. If you have any queries regarding completing it, then please ask a member of staff for assistance. All information will be held in strictest confidence.

GDPR: in line with clinical policy we will normally keep your data for a minimum of 7 years.

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PRIME CONTACT DETAILS/NEXT OF KIN

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HOW DO YOU WISH TO BE CONTACTED? PLEASE TICK HOW YOU WISH TO BE CONTACTED FOR:

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(Leave blank if you do NOT wish to share your information)

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REASONS FOR SEEKING TREATMENT AT THE ACHILLES CENTRE

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Ensure file size does NOT exceed 4MB

MEDICAL HISTORY

If there has been a change in your medical history the treating practitioner will discuss this further with you during your appointment.

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Please list all prescribed medication

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Please list all non-prescribed medication

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I understand that if I have been referred for treatment via a third party, that my referring agent may be contacted regarding my care (Leave blank if you do NOT wish to share your information)

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If you cannot see the submit button, it is because you have NOT yet agreed to all of the necessary terms.

 

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