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Icon 1Registration Details Step 1 of 4

Contact Details & DOB...

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Your Address...

Where Do You Work?...

How did you hear about us...

We'd really like to say thank you please provide their details and email address/phone number if you have it

Your GP Details…

If we need to contact your GP, we will ask you before we do this.
If you don't want us to at all please let us know.*

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Your Insurance Company Details…

Limitations*

Icon 2Further information Step 2 of 4

Service details...

Important information about your appointment...

Icon 3Medication / Previous Conditions Step 3 of 4

About Your Previous Conditions...

Medication...

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Other...

Emergency Contact Details...

Icon 3Consent to session at Perfect Balance Clinic Step 4 of 4

I am happy to consent for a consultation at Perfect Balance Clinic

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Thank You Step 4 of 4

Thank you for completing the initial registration form. This will help during your appointment as we will be able to concentrate on helping you.

We take our data protection seriously and no information will be shared or otherwise used except for the purposes intended.


By registering with the clinic and sending this application you are agreeing to abide by our 24 hour cancellation policy, details of which can be sent to you should you wish.

Send Application