New Client FormDr Michelle Clark Name * First Name Last Name Date of birth MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Mobile Phone (###) ### #### Email Occupation * GP name and address * GP Telephone (###) ### #### How are you paying? * Paying for treatment yourself Private health insurance Insurance Insurance note: We will endeavour to claim all fees for treatment/services from the relevant insurance company. However, any fees not paid by the insurance company must be paid for by you or your representative. Please tell us your insurer name AXA PPP Aviva CIGNA WPA BUPA VITALITY Membership/policy number Authorisation/claim code Date of policy expiry or renewal MM DD YYYY Policy excess (if required) £ How did you hear about us? * Friend/family GP / Consultant Clinic sign Google Other professional Other If other, please state Thank you. Your responses have been submitted to your therapist.
