Request your free consultation with a Cardinal Clinic nurse.
Are you the person requiring support or are you completing this form on behalf of somebody else?
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I am the person requiring support
I am completing this for somebody else
Should we make arrangements for the consultation with you or with the person who requires our support?
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Please contact me.
Please contact the person requiring support.
About the Person Requiring Support
Name
First Name
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Date of Birth
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Email
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Phone Number
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Brief Description of The Reason For Contacting Us
Has Your GP Recommended You Seek Specialist Support?
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About The Person Completing This Form
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Phone Number
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Relationship to the Person Requiring our Support
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Other Information
Cardinal Clinic Fees
As an independent hospital, all fees must be paid for by an employer, a health insurance policy or by the person receiving care. We are unable to accept NHS patients at Cardinal Clinic.
Please advise how fees would be settled.
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I will pay the fees myself
I have a health insurance policy
My employer will pay the fees
How Did You Hear of Cardinal Clinic
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Internet Search
Social Media Advert
Recommendation from Friend or Family
Recommendation from GP
Please Confirm You Consent to Cardinal Clinic Contacting You With Regards To Your Enquiry
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Please Confirm That You Have Read and Consent to Our Data Security Policies. Please note that we will be unable to provide this service without your consent.
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https://cardinalclinic.co.uk/privacy-policy/
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