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Email *  In providing me with an email address you are consenting to receive appointment confirmation and reminder emails, as well as it being used for other administration purposes (including a yearly patient survey). You can opt out of these at any stage by emailing me, or by filling in this field with 'None'. Please be aware however that in doing so you won't get any email reminders and patients are charged for missed appointments and cancellations with less than 24hrs notice.
First Name *
Last Name *
Home Telephone Number  Your telephone numbers will be used for clinic administrative purposes only. You may opt out of receiving phone calls on your home line or mobile by leaving either of these fields blank, but I do need to have at least one phone number to contact you on.
Mobile Phone For SMS Notifications  Please make sure that you include the country code. For example, the UK number 07777123456 becomes +447777123456. The system sends out automatic appointment reminders at 8am on the morning of your appointment. You can opt out of these by leaving this field blank, but please be aware that I have a 24hr cancellation policy and missed appointments will be charged for.
Work Telephone Number  (as appropriate)
Address Line 1  Your address will be used for clinic administrative purposes.
Address Line 2
By ticking this box you are consenting to being treated in the manner described by the Patient Information About Osteopathic Treatment page, and the COVID-19 SPECIAL MEASURES.  Please read the Patient Information About Osteopathic Treatment and COVID-19 SPECIAL MEASURES pages before ticking this box; This is available on my website at https://nunobento.co.uk/first-osteopaths-appointment/, https://nunobento.co.uk/covid-19-special-measures/ and on the wall in the clinic lobby.
By ticking this box you are consenting to your personal information being used according to the General Data Protection Regulations as described in my Privacy Notice.  Please read the Privacy Notice for a detailed description of how the information you provide is handled and used; this is available on my website at https://nunobento.co.uk/gdpr-2018-privacy-notice/, and on the wall in the clinic lobby. Your patient notes will include details about medication, previous treatments/conditions and other issues concerning your health. These medical records will be kept securely for at least 8 years after treatment has ceased (or in the case of a minor, until they are at least 25 years old), in order to comply with legal requirements.
Promotional material  If you are happy for us to use your contact details for providing promotional information (such as offers and advice), please tick this box. Your information will never be shared with third parties.
Sign up to my Blog  If you tick this box you will receive an email with every new post I write covering a range of topics relevant to osteopathy, ergonomics, managing back pain, meditation and general health. New topics usually come out once a month, and you can unsubscribe at any stage by simply emailing me accordingly.
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Appointment scheduling software by hitAppoint