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First name*

Last name*

Email*

Phone number*

Street address*

Medicare Number*

Medicare Individual Reference Number (IRN)*

The position number of a person on a Medicare card.

Are you over 18 years old?*

Yes

Do you suffer from a chronic condition that has been untreated for more than 3 months?*

Yes

Have you tried other conventional treatments for your condition without success or experienced significant side effects?*

You may not be eligible for an appointment with Telegreen if you have not tried other conventional treatments.

Yes

Telegreen Medical is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you:

I agree to receive other communications from Telegreen Medical.*

You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy.

By clicking book an appointment below, you consent to allow Telegreen Medical to store and process the personal information submitted above to provide you the services requested.