Name

First Name

Last Name

Email Address

Address

Post Code

Phone

Date of Birth

i.e 14/11/1990

GP - Name & Practise address

Gym/Clinic

Payment Details

Name on card

Card Number

16 digits across middle of card

cvv

3 digits on reverse of card

Card Type

Visa

Visa debit

Mastercard

Other

Expiry date

11/20

Consent for Examination & Treatment

I understand that any diagnostic material recorded by this clinic remains the property of the clinic and will only be released to other parties with my prior agreement, and that all clinic files are subject to internal and/or external audit by a qualified and appointed person(s). In case of treatment to a minor, or a patient who is recognised to have diminished intellectual capacity, this consent is to be signed by either parent or legal guardian, this fact being appropriately noted below. I hereby consent to a physical examination by a qualified clinician in order to establish a diagnosis and to any subsequent treatment and/ or rehabilitation prescribe. Data Protection Bounce values you as a client and complies with the new GPDR legislation to protect your data. We will process the data given above according to our privacy policy- please see below.

I have read and accept the Terms & Conditions - see below

Consent for Examination & Treatment

I understand there is a 24hr cancellation policy & consent to Brightline Performance Ltd using my card details to take payment for any outstanding balance on my account. An email of the invoice will be sent to me giving details of the charge.

Please tick the box to authorise us to contact you by email from our membership/scheduling system EZ facility to setup your email preferences and and your contract above.

Clinic form