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Belfast Hospital: 028 9066 7878

North West Hospital: 028 7776 3090

Cross Border Health: 048 9068 8858

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Kingsbridge Membership Club Registration

Many thanks for your interest in Platinum Membership with the Kingsbridge Membership Club.

To complete your registration and to get access to the range of benfits associated with 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)

Personal Details

Name * Address * Date of Birth * Contact Number * Email *

Membership Plan

Please select Membership Plan *

Individual Membership: £50

Family Membership: £95

Nominated Family Member 1 (if applicable)

Name Date of Birth Contact Number Email

Nominated Family Member 2 (if applicable)

Name Date of Birth Contact Number Email

Nominated Family Member 3 (if applicable)

Name Date of Birth Contact Number Email

Long Term or Chronic Illness?

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

Yes

No

If 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 *

I have read and accepted Membership Terms & Conditions

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Help & Support

Kingsbridge Help & Support

For enquires on post operative support, cancellations, test results and payment

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