Application for low-cost appointment
This is an application for our pay-what-you-can clinic. 

Filling out this form is non-binding, you can decide whether you want to go ahead with the appointment at a later date. 

Appointments will be offered to those who we feel would most benefit from our clinic and wouldn't otherwise be able to access this kind of support. If you are accepted for an appointment you will be offered to book an appointment and be given 48 hours to do so, after that the appointments will be offered to those on the waitlist, on a first-come, first-served basis. 

Privacy notice: The information kept here is data-protected, encrypted and will be permanently deleted after the clinic date.
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Name *
Date of Birth *
MM
/
DD
/
YYYY
Location (City, Country) *
Reason for appointment. What is it that you want dietetic support for? *
Relevant Medical History *
Current weight and height, or estimate. (We need this information to understand risk-level) *
How open you are to change/ how receptive you feel to dietary advice? *
Reason for accessing low-cost treatment: *
Email address so we can contact you if you are accepted for an appointment *
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