Contact form on website

Request an appointment or make an enquiry

Complete the details below and we will be in touch with you as soon as possible. Do not use this form for medical emergencies.
Title*
Name*
Phone Number*

Area codeNumber
Email*
Age *
Which of our services are you interested in? Please select one option*
Where are you located?*
How can we help?*

0/40
How would you prefer to be contacted?*

TelephoneEmailEither
How did you hear about us?*
Payment method*
IMPORTANT NOTE IF YOU HAVE PRIVATE MEDICAL INSURANCE:

Appointments for ADULTS with skin growths, moles and suspected skin cancers are available under certain private medical insurances.

Other appointments such as hair loss, acne, scarring, laser treatment, children's dermatology & general dermatology ARE NOT AVAILABLE under medical insurance.

You must ensure your enquiry is for a skin growth, mole or skin cancer and provide valid pre-authorisation details to be offered an appointment under private medical insurance. If you are not sure please call the office for clarification.
Please state your UK health insurance company. Please ensure your request is for a skin lesion or suspected skin cancer in an adult if you are using private medical insurance.*
Will you require a foreign language interpreter?*

NoYes
Which language will you require an interpreter for?
The clinic is located on the first floor accessed via a flight of stairs. Are you able to climb a flight of stairs?*

Yes I can climb a flight of stairsNo I can not climb a flight of stairs
IMPORTANT NOTICE ABOUT ACCESS FOR WHEELCHAIR USERS OR ANYONE UNABLE TO CLIMB STAIRS

Please take a moment to review our access statement.

As the clinic is not accessible for wheelchair users or anyone unable to climb stairs, the options we will be able to offer you are:
- Online video or telephone consultations, where clinically appropriate.
- Information about accessible local providers offering face to face dermatology or laser treatment.

Declarations
Please take a moment to read our:
- appointment guide
- terms and conditions
- privacy policy
- fees
- Information on same day procedures
I confirm that:*

I am in the UK (you must be in the UK at the time of a consultation )I understand and accept the appointment guide, terms and conditions, privacy policy and fees.
Are you interested in hearing from us?

I would like to receive occasional emails which include our latest news, updates and helpful tips. You can unsubscribe at any time.
Should be Empty:

Request an appointment or make an enquiry