Name
Date of birth
Next of Kin/ Emergency Contact Name
Do you consent to us leaving voicemail messages?
Do you consent to us corresponding with you using the email address provided?
Are you currently experiencing difficulties with any of the following? (please check all that apply)
Are you registered disabled?
Where would you like the MOT to take place?
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We have 10 clinicians with availability, so please be sure to try a different clinician if the one selected is not available on your preferred time/date

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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.

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.

Please check this box to confirm that you 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

Thank You for completing our registration form. We will contact you within 3-5 working days to arrange your first appointment.