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Loyalty Reward Scheme Form
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Wellbeing & Health
The Loyalty Reward Scheme has been designed to offer discounts to our existing clients. Before completing this form please ensure that you have read the page LOYALTY REWARD SCHEME and understand its contents. If you are an existing client you should obtain permission from the person you are introducing to us before completing this form. If you are a new client to Wellbeing & Health please ensure that you enter the details of the person who introduced you to us as discount cannot be claimed at a later stage.

*indicates required fields 
  *Are you an existing client:  Yes
 No
  *Are you a new client:  Yes
 No
  *Existing Client - Name:
  *Date of Birth:
  *Address:
  *Telephone Number:
  Email Address:
  *New Client - Name:
  *Date of Birth:
  *Address:
  *Telephone Number:
  Email Address:

Please ensure you have completed all sections of the form and then click the SUBMIT button. Alternatively print the page and post it or pop it into the clinic.
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