New Patient Online Registration Form


How did you hear about this clinic?

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GP/Consultant

Do you give us permission to write to your GP, Consultant, or insurer regarding your treatment?

NoYes

We send a monthly health newsletter to all of our patients. Tick here if you would prefer not to receive it?


Insurance

We only have direct billing agreements with BUPA and AXA/PPP.

Please obtain an insurance form from reception if you are claiming through one of these insurers.

Other insurers: Payment must be made at each visit. We will provide an itemised invoice in order for you to claim reimbursement directly.

Consent and Cancellation Policy

I understand that I am responsible for the full cost of my treatment, and agree to pay the fees for treatment at the end of each appointment.

I understand that should I fail to attend an appointment without 24 hours notice I will be liable for the full cost of the treatment.

Signature

£10 Voucher *New patients only

Back pain, knee and shoulder pain, are just a few of the common conditions we treat…

Book your appointment today to see one of our specialists in either our Canary Wharf or Marble Arch clinic.

Contact us