Expression of Interest Form – MediMinds Programme
Thank you for your interest in the MediMinds programme. To help us organise and assign sessions effectively, please complete the form below. All information provided will remain confidential.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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What session time would suit you best? Select all that apply.
*
Weekday afternoons (1.30pm start)
Weekday evenings (6.30pm start)
Saturday morning
Saturday afternoon
Other
Have you had a referral to our service?
*
Yes
No
Please enter your NHI (National Health Index) Number, this can be found on your medical records and prescriptions, e.g., ABC1234.
*
Please enter the name of your GP and their current practice.
*
Please provide any additional details or specific requests you think might help us support you effectively:
By submitting this form, I acknowledge that the information provided is accurate to the best of my knowledge. I understand that this form is for initial consultation purposes, and further details, including session rates and agreements, will be provided upon review.
I agree
I do not agree
Submit
Should be Empty: