First name (required)
[text* first-name]

Last name (required)
[text* last-name]

Your e-mail (required)
[email* your-email]

Date of birth (required)
[date* date-176 min:1900-01-01 max:2010-01-01 id:dob]

Phone number (required; landline and mobile if possible)
[text* text-207]

Request to see (required): [select menu-26 id:requestToSee include_blank “Doctor” “Nurse Practitioner” “Physiotherapist” “Other”]

Which Doctor / Nurse / etc. would you like to see (or leave blank if you don’t mind which)?
[text text-207 id:chosenDoc]

Requested date (required)
[date* date-177 min:2016-01-01 max:2010-01-01 id:reqDate1]

Preferred time
[text* text-207 id:reqTime1]

Alternative date (required)
[date* date-178 min:2016-01-01 max:2010-01-01 id:reqDate2]

Preferred time
[text* text-208 id:reqTime2]

Notes
[textarea textarea-125 id:notes]

How should we contact you back? [radio radio-738 id:whichContactMethod “Phone” “Text”]

Consent (required)
May we update or add your email address to your patient record? We may contact you by e-mail from time to time with important information about the practice or your health. We never sell, lend or distribute patient details to unrelated third parties except the Department of Health as agreed on your enrolment form. All use of your personal information complies with the Privacy Act.
I consent (please tick:) [acceptance acceptance-148]

[recaptcha]

[submit “Send”]

[your-subject]
[your-name]
From: [your-name] <[your-email]>
Subject: [your-subject]

Message Body:
[your-message]


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Message Body:
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Patients registered with us can use this form to request a weekday appointment at least 7 working days from now.

We can book appointments on weekdays, not on weeknights, weekends, public holidays, or the period between Christmas and New Year.

For urgent requests please call your medical centre directly 000000.  Please also call direct if you wish to cancel your appointment.

In an emergency dial 999.

Please note, all appointment requests received before 12 noon will be processed that day. We will try to book an appointment on the day you have asked for, but in our busy practice this may not always be possible.

Paris

First Health
15, rue de Lappe
75011 Paris

+33 1 00 00 00 00

Contact us!

Munich

First Health
Hohenzollernstr. 15
80796 München

+49 89 000000

Contact us!

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