General enquiry form

General enquiry form

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Please note we are unable to provide medical advice, for this you will need to see a consultant.

Name
Address


Post Code
Telephone
Email

How would you like us to contact you?
	By phone By email By post

Your age group:
					18 - 29	30 - 39	40 - 49	50 - 59
					60 - 69	70 - 79	over 80

Which treatments or services are you interested in?
	Cosmetic surgery	ETS surgery for blushing
	GP service	IVF and fertility
	MRI scanning	Orthopaedic & sports injuries clinic
	Physiotherapy	Screening services
	Ultrasound	Varicose veins (laser)
	Weight-loss surgery	X-ray
	Other (please enter speciality)

Do you have private medical insurance?
	Yes	No

How did you hear about us?
GP	Newspaper	NHS Hospital/GP Patient Handbook
Yellow Pages	Magazine	Personal Recommendation
Internet	Previous Treatment	Other

Do you have any particular questions that you would like us to answer at this stage?


or

Highgate Hospital - 17-19 View Road - Highgate - London N6 4DJ - T: 020 8341 4182 - F: 020 8347 3898 - E: info@highgatehospital.co.uk
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Cosmetic surgery

Our consultants

Patient information

Saturday 31 July 2010

General enquiry form