T4H Low Cost Clinic (LCC) Referral Form

This form is to refer yourself or someone else to our Low Cost Clinic (£) held in the centre in SE23 between 10am and 3pm for physical treatments. Please fill out the following form to help us understand your physical condition and someone will be in contact with you. Fixed bookings need to be made.

Tick if you suffer from any of the following:
Tick if you suffer from any of the following:
Have you had a positive Covid-19 test?
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Are you pregnant?
Do you have a pacemaker?
Are you on any medication?
Are you registered disabled and/or have a life limiting condition?

Thanks for submitting!