Request for Appointment

Name *

Address *

Date of Birth *

Home Phone Number *

Mobile Number *

Email Address *

GP Name and Practice Address *

Brief History of Symptoms *

What treatment have you had for this condition? *

Have you had an MRI scan within the last 12 months? *

Insurance Company. Membership Number. Authorisation Code *

Please choose which day you wish to attend *

Monday morning – Ulster Independent Clinic

Wednesday morning – The Ulster Independent Clinic

Thursday evening – The Ulster Independent Clinic

Please click the submit button and our office will contact you as soon as possible.