Your Name:
Company:
Phone Number:

Clinic

I would like to book an appointment at the following clinic:
Date
I would like to book an appointment on the following date:
Time

I would like to book an appointment at the following time:
(or) please specify a time and we will book the closest available:

Procedure
I would like to book the following procedures:

Tick for Fastrack 
Tick for CBH 


Payment

My PO number for this booking is:
I do not have a PO and will provide one at a later time 
NOTES

Please note that there is a 48 hour cancellation policy for bookings.
All bookings to be paid by payment card will require you to call the bookings department.
For Onsite bookings, please call the bookings department for availability and cost.