I confirm that I'm a self-paying patient * Yes No - please contact Member Services
Title * Mr. Mrs. Ms. Dr. Prof.
First Name *
Surname *
Email address *
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Contact number (no spaces) *
Date of birth *
Do you have a treatment in mind? * Urology
How did you hear about us? * Press / Magazine article/advert Reception Magazine / Newspaper leaflet Online Search Consultant Referral Doctify Go Private Email GP Referral Partnerships (local businesses) Referred by York Social Media Website PMI Referral Word of mouth Hospital poster Not stated Other Changing pathway Returning Patient Webinar TV (Benenden Health advert)
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