This in an online appointment request system for Central Sexual Health Services. Please complete the following template with your details and we will call you back within 2 working days with an appointment time. The appointment service phoneline is open Monday – Friday (8:30am – 12:30pm).

Name:

Email:

Date of Birth: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901

Gender: Male Female

Address:

Postcode:

Telephone:

Comments:

We will contact you by telephone or email within 2 working days to arrange an appointment.

Your information is transmitted to us electronically in a non-secure way. As with any non-secure electronic communication, there is a chance that your information may be intercepted and viewed by someone else. Unfortunately we cannot accept any responsibility for any damages or loss whatsoever caused by the interception of your personal information. After we have received your completed appointment request, only the contact details you provide at this stage will be retained in the files of the Central Sexual Health, this will be destroyed once your appointment is processed. The information you provide on this form will be treated as highly confidential, and will not be passed on to anyone else.

I confirm that I have read and agreed to the Confidentiality and Data Protection Policy