Please click on the speciality below which may be of interest to you for more detailed information.

Client Information Form

Please fill in the relevant information below and press submit, or you can download a printable version here and Post or Fax it to 01 4928040

Client Name:

Speciality:

Letters required after your name on bill heads

PPS number

Insurance Company Doctor Numbers

VHI:

Quinn Health:

AVIVA Health:

GMA:

Correspondence address:

Contact Number:

Contact Email Address:

Secretary's name (if applicable):

Phone:

Email:

Sort Code:

Account Number:

Please ensure that your E-Mail address is entered correctly.