Medico Legal Marketing Application
Please complete the form below:
Title
*
Name
*
Occupation
*
Clinic Address
*
Post Code
*
Office Telephone
*
Fax
Email Address
*
Address for Correspondence (if different from above)
Post Code
Telephone
Fax
Domiciliary Visits Y/N
(distance from location)
*
Minimum age you will see a client
*
CV -
click "Browse..." button to attach
(Leave blank if not submitting a CV)
Areas of specialty/interest within field of expertise
*
Maximum Payment Terms
*
6 months
12 months
End of case
Fee for Standard Report
*
Sample Report, if available -
click "Browse..." button to attach
(Leave blank if not submitting a report)
GMC Number
MDU Number
MRO's currently registered with
By submitting this form, I authorize Medical Legal Marketing to undertake marketing on my behalf and to distribute my CV, sample report and contact information to organizations it feels appropriate.
Medico Legal Marketing take your online protection very seriously which is why we use PayPal for payment collection. PayPal use the maximum strength encrypted technology supported by the consumer’s browser using a Secure Socket Layer in all of their communication with you, ensuring maximum safety when paying online.
Please note that it is no longer necessary to create a PayPal account in order to pay using PayPal. You can now pay using any credit card via PayPal in the same way as you would through any other payment gateway.
