Eastbourne Clinic Enquiry Form

Enquiry Form

This information is requested so that we can offer appropriate advice / support for those who request it. All information is treated in the strictest confidence in accordance with the Data Protection Act. Those who prefer not to answer some of the questions below are under no obligation to do so.

1. Please provide the following contact information:
(Fields marked with a * are required.)

Title:	*
Full Name:	*
Address:	*

County:	*
Post Code:	*
Telephone Number:	*
E-Mail:

2. Are you over or under 65 years of age?

	Under 65 years of age.
	Over 65 years of age.

3. I have been unwell for:

4. Have you seen a doctor?

	Yes
	No

5. If Yes to question 5 above - what did the doctor prescribe?

6. My doctor has given me a diagnosis of:

7. Have you suffered from previous mental illness?

	Yes
	No

8. If Yes to question 8 above - what was the nature / diagnosis of the illness?

9. The main features / symptoms of my illness now are:

10. Please tell us any information that you feel is relevant or helpful to us:

If you are okay with the information entered please click on the SEND FORM button below:

©2006, The Eastbourne Clinic
The Eastbourne Clinic, Grange Road, Eastbourne, East Sussex BN21 4HE
Telephone: (01323) 430831

All information is subject to change without notice, please feel free to contact us for more information.