Registration Form

Instructions: Please complete all sections of this registration form for your application to be considered. If successful, a Direct Debit mandate will be sent to the email address provided. (if not seen in inbox , please check junk mail folder)

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Current Medical Issue

Refund Policy

I understand that no refunds will be issued for any partial months. I may cancel my registration at any time, but any fees paid for the current month are non-refundable.

Yes

I have read and agree to the Terms and Conditions of Wellspring Private GP Clinic, available via the link in the footer of this website.

Yes

I confirm that I am 18 years or older.

Yes

Have you had either one 30 minute unregistered patient appointment or two 15-minute unregistered patient appointments ?

Yes

No*

*If the criteria has not been met  this form will be taken as a declaration of intent to  register. There is a then 3 month grace period to meet the  criteria.

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Hours

Monday – Friday
9am – 7pm

Cookie Policy

terms and conditions

Non-discrimination Policy

countersigned GPs

Wellspring Private GP Clinic
Regus,

The Pavilions,

Albert Edward House
Ashton-on-Ribble, Preston
PR2 2YB

For inquiries:
wellspringprivategp@outlook.com

Registration Form

Thank you and All the best!

Hours