CHEST XRAY ONLY BOOKING REQUEST FORM
Full Name:
Date of Birth:
Address:
Email:
Contact Number:
Passport Number:
Country Visa
Required For:
Country of Issue:
Date of Issue:
Date of Expiry:
Australian Applicants:
Hap ID or TRN number
Canadian Applicants:
UCI/UMI/IME number (if available)
New Zealand Applicants:
NZER/NZHR number (if available)
Visa Category applied for:
Length of Stay:
Intended Occupation (if applicable):
To your appointment please:
 Bridge Clinic Immigration Registration Form (available on website)
 Passport (Mandatory)
 1 other form of ID (driving licence etc)
 If you have spent 28 days or longer in Afghanistan, Cameroon, Equatorial
Guinea, Ethiopia, Iraq, Nigeria, Pakistan, Somalia or Syria or in any
combination of these countries, on or after 05 May 2014, you will need to
provide evidence of polio vaccination. Please bring this to your
appointment.
Cost:
£95 (cards, cheques and cash are accepted).
Payment will be taken at the end of your appointment.
Once you have completed this form please email it to xray@bridge-clinic.com or
fax it for the attention of the Xray Department to 01628 760909