electronic appointment form

Please fill in the form below and give us much information as possible. Remember, Mr. Magos sees private patients on Wednesday mornings.

Name:  
Address:  
City/Town:  
Post code:  
Country:  
Telephone:  
Email:  
Date of birth :  
What is your medical problem:
  
Preferred date for appointment:
  
Preferred time for appointment:
  
Medical insurance details:
  
Have you seen Mr. Magos before:
  
Other information :
  
   

Press "Submit" when you have finished, or "Reset" if you wish to start again.