Request for Appointment

Name *

Address * Address

Date of Birth *

Home Phone Number *

Mobile Number *

Email Address *

GP Name and Practice Address * GP Name and Practice Address

Brief History of Symptoms * Brief History of Symptoms

What treatment have you had for this condition? * What treatment have you had for this condition?

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

Insurance Company. Membership Number. Authorisation Code * 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

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