Book your AzuraMOT
What we do
AzuraMOT
Technicians
Make an enquiry
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Book your AzuraMOT
To book please call 07713 155671 or use the booking form below
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Step
1
of 3
Personal Details
Name
*
First
Last
Email
*
Date of Birth
*
Primary Contact Number
*
Secondary Contact Details eg Mobile Phone
Next of Kin/ Emergency Contact Name
*
First
Last
Next of Kin/ emergency contact number
Do you consent to us leaving voicemail messages?
*
Yes
No
Do you consent to us corresponding with you using the email address provided
*
Yes
No
Employment Details
Employer Code (where applicable)
Employer Name
*
Your Current job Title
*
Current Salary
*
Less than £50K
£50k - £75K
£75k - £100k
£100k - £150k
Over £150k
Next
Current Health and Wellbeing
Are you currently experiencing difficulties with any of the following? (please check all that apply)
*
Stress
Depression
Anxiety
Substance Misuse
Alcohol Misuse
Managing Work/Career
Relationship/ Sexual issues
Physical Health
Sleeping
Managing Nutrition/ Diet
Finances
Bereavement
Other
I do not currently suffer from any of these presenting issues
If you answered other to the previous question please give details here
Are you registered disabled?
*
Yes
No
Health Conditions: If you checked any of the boxes in the previous section please use this field to give further details
Next
Availability
Please specify which days you would be available to attend a one to one session. Our opening hours are 8am - 9pm every day. (please check all that apply)
Days of the week you are available?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Please specify the times you are available? (Please note our working hours are 8am - 8pm)
*
Morning; 8am - 12pm
Lunch; 12 - 2pm
Afternoon; 2 - 5pm
Evening; 5 - 9pm
Available anytime
Please select your preference for how you would like your AzuraMOT?
Face-to-face at our Harley Street Clinic
Via Zoom Video call
No Preference
File Upload
Click or drag a file to this area to upload.
Confidentiality
Confidentiality AzuraMinds takes confidentiality and data protection extremely seriously and we manage, store and use your personal data for the purposes of your treatment only. We ensure complete confidentiality throughout any contact with AzuraMinds, whilst responding appropriately to any situation where there is a risk of harm to self or others, as we are legally required. Data Protection By signing this form I consent to relevant information about my condition and treatment being shared between a multi-disciplinary team of health professionals at AzuraMinds involved in my care. Once form is completed Thank you for contacting us. We will be in touch within the next 3-5 days to arrange your AzuraMOT.
Data Protection
By signing this form I confirm that I understand that a multi-disciplinary team of health professionals at AzuraMinds may be involved in my care and will share relevant information about my condition and treatment.
Please check this box to confirm that you have read and agree to the Confidentiality and Data Protection Statements above
*
I have read and agree to the Confidentiality and Data Protection statements above
Please check the box below to confirm that you understand that any AzuraMOT appointments cancelled less than 48 hours prior to the arranged appointment time and date will be charged at full rate
*
I understand and accept that I will be charged at the full rate for the appointment if cancelling less than 48 hours before the scheduled appointment time.
Thank You for completing our registration form. We will contact you within 3-5 working days to arrange your first appointment
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Book your AzuraMOT
