We appreciate your comments and suggestions and welcome
enquiries.
If you are already registered as a patient at The
Burghley Park Clinic and wish to complete the following
forms please
If you are not yet registered as a patient and would like to make contact
with the clinic and register your interest in attending the clinic, please
use the following form:-
You may be interested to note that many of the enquiries
that we receive at The Clinic are from people who have not
sought assistance from a medical clinic before. Please do not put off contacting us - we have a rule "no
question, (however obvious the answer) is ever considered
silly" - we will have been asked most things before and it
is important that you feel comfortable about all aspects of
your treatment before we start treating you.
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Title* |
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Forename*
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Surname*
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House Name or Number*
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Street*
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Address 2* |
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Town* |
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County |
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Postcode*
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Country:* |
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Daytime Telephone Number*
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Mobile Telephone Number |
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Email Address* |
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Please
tick here
to confirm that you are over 16 years of age ( for all laser acne
treatment enquiries)
Or
over 18 years of age (for all other treatment enquiries) |
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Date of Birth DD/MM/YYYY (entirely optional)
Gender please
Female
Male
Other |
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Would you like to know more about any of the following treatments or
areas that concern or bother you? |
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What would you like us to do?
I
would like you to contact me to arrange a
consultation please
I would like you to send me a Brochure
I would like you to send me a
Client Guide to
Services
I would like a
call from a staff member of the clinic to discuss things further.
Preferred Time/Day for call back
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Please may we ask where did you hear about us? |
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Please may we ask did
you use a web search engine and if so which one? |
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If you do not wish to receive other marketing related material from
us, either by e-mail, SMS or by post, please tick this box
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