Title
*
Mr.
Mrs.
Miss.
Ms,
Mst.
Dr.
Name
*
First Name
Last Name
Date of Birth
*
Age
*
Contact Telephone Number
*
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Marital Status
Married
Single
Widowed
Divorced
Sex
How did you hear about us?
*
I would like help for
*
Other problems I am concerned with
*
Car accident(s) when? Injuries?
Other personal injuries/accident(s) when? Injuries?
Exercise programs/sporting activities?
Supports - Back/Foot?
Operations?
Drugs/Medicines/Vitamins - Type/Dosage etc.?
*
Have you ever had spinal care before?
*
If yes, please tell us the name of the practitioner/practice, location and what you were being treated for
General Symptoms
*
Please tick any of the following symptoms or problems as they apply to you.
Other, please specify
Muscle and Joint
*
Pain or numbness in
*
Have you ever had any of these diseases or disorders
*
Other
If other, please give details
Are you pregnant?
No
Yes
Consultation
*
Please note that to secure your new patient appointment, we require a £50 holding deposit. This deposit will be deducted from your first visit or any services rendered. If there is any problem attending your confirmed appointment, please call us on 01227 477 004 or email admin@hopespinalwellness.co.uk so we can arrange an alternative time to avoid disappointment. This deposit is non-refundable and non-transferable if you fail to attend without prior notification.
If X-rays are required, please understand that the fee charged is for taking, processing and reading the images. They remain part of your permanent case files at Hope Spinal Wellness. Fee for new patient consultation and examination is £80. If X-rays are required the fee is an additional £100.
I understand that no accounts are rendered by this centre and we accept cash, card, cheque or online payment.
Marketing
*
I am happy to receive health information, free information guides and practice updates from Hope Spinal Wellness. We never pass your details onto any advertisers. Hope Spinal Wellness Privacy Policy Note is available on our website or by request
Thank you!
To secure your new patient appointment, we request a holding deposit of £50.This deposit will be deducted from your first visit or any services rendered. If there is any problem attending your confirmed appointment, please call us on 01227 477 004 or email admin@hopespinalwellness.co.uk so we can arrange an alternative time and to avoid disappointment as the deposit is non-refundable and non-transferable if you fail to attend without prior notification.
CLINK HERE TO SECURE YOUR NEW PATIENT APPOINTMENT
