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Kingsbridge GP Subscription Registration

Many thanks for your interest in our GP Subscription Plan.

Many thanks for your interest in our monthly 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).

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

Captcha *

* Required

Help & Support

Kingsbridge Help & Support

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