Consultation Request Form | Chase de Vere Medical

Please complete the form to request your initial complimentary appointment. Appointments will take approximately 60 to 90 minutes, in person, by video or by phone – your choice. Together, we will build a picture of where you are now, where you want to be in the future, and start thinking about how best to get there.

What dates and times work best for you?

Please give us at least two different options

Are you a BMA member?

YesNo

I consent to sharing my personal data with the BMA so that they can contact me to measure my satisfaction with Chase de Vere’s services.

Step 7

Your Details

Title *

First Name *

Last Name *

Date of Birth *

Email Address *

Contact Number *

Address *

Postcode *

Preferred Meeting Format? *

Have you taken advice from us previously?YesNo

I'd like to receive occasional messages from Chase de Vere via email, post, SMS, phone and other electronic means to enable Chase de Vere to share with you the latest financial news and opinion. We will not share your details with anyone else. You will be able to opt out of these messages at any time and we always provide an option to do so in our communications with you.

I confirm and acknowledge that I have read Chase de Vere Medical's Privacy Notice and consent to you using the details I have provided, which includes any BMA trade union membership, which is classed as sensitive personal data, to contact me with a view to arranging an initial consultation / attending an event with Chase de Vere Medical.