Home About Us Kingsbridge GP Subscription Registration

Kingsbridge GP Subscription Registration

Many thanks for your interest in our GP Subscription Plan.

In order for us to finalise your registration and provide you with access to the range of benefits associated with our Kingsbridge Platinum Membership, please provide us with the details requested below for yourself, and up to 3 persons nominated to benefit from your platinum Membership (1 other adult and two children under-18, living at the same address).

"*" indicates required fields

Personal Details

Name*

First Last

Address*

Street Address Address Line 2 City Post code

Email*

Contact Number*

Please select Membership Plan*

Individual Membership: £50

Family Membership: £95

Nominated Family Member 1 (if applicable)

Name

First Last

Date of Birth

Contact Number

Nominated Family Member 2 (if applicable)

Name

First Last

Date of Birth

Contact Number

Nominated Family Member 3 (if applicable)

Name

First Last

Date of Birth

Contact Number

Long Term or Chronic Illness?

Do you/your nominated family members suffer from any long term or chronic illness*

Yes

Please supply details*

Signature

Signed*

By signing below, I agree to the terms and conditions outlined in the Platinum Membership Terms and Conditions document

Date*