New Patient request for our Questionnaire©:

Please fill out and submit the form below.
If you are a candidate for our treatment we will send you a secure link to complete an extensive online questionnaire.
Your Last Name:  

Your First Name:  

Your e-mail address:  

Please repeat your e-mail:  

Please choose a familiar username

Enter a username:  

We shall use this username when sending you a password

Please provide a brief description of the reasons why you seek a consultation:

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Result: (please write the computed result of the equation, do not copy it)

*You will be refunded the full fees if your application is not accepted for our system of care and research.

This sum will be deducted from the consultation fee if you undergo a consultation for treatment.

We are registered with the Information Commissioners Office (ICO) and we fully comply with the provisions of the Data Protection Act ensuring that your data is in safe hands.

If you would like more information about the types of treatment conducted at our practice, we recommend you browse our website where it is easy to learn more about the conditions we treat and how we treat them. We especially recommend you read our patient testimonials.