Please complete all information fields.

Once you have submitted this form, please be available to take the phone call within the next 10 minutes - 1 hour. However, during our busy times, this may be up to 2 hours. Please be aware, the call will come from a withheld number.

Telephone 999 for an ambulance if you have experienced any of the following in the last 24 hours after your treatment:

• loss of consciousness
• severe allergic reaction
• a confused state
• concern for a heart attack or stroke
• chest pain
• slurred speech
• breathing difficulties
• fits that aren't stopping