Payment Details-old

** please note all Personal details fields must be completed **

Personal Details

title (e.g. Mr/Mrs/Miss etc.)

forename

surname

house no. or name

street

area

postal town

postcode

email

telephone number

Treatment Details

Type of Treatment:

Physiotherapy

Podiatry

Massage

Pilates

Other

name of therapist

clinic

invoice/receipt number

total amount (£)

additional information