Returning Customer Health Insurance Form For Returning Clients IntroAuthorisationInsurance Cover ActivationPersonal & Session DetailsConfirmation Takes ~ 5 min Activate Your Health Insurance FastWe guide you through, step-by-step.Fill this in once - and we’ll handle everything else.Most clients complete this in under 5 minutes and get their treatment costs covered.PreviousNext Enter Your Details to Activate Your Insurance Cover ⚠️ Your details must match your insurance policy exactly. Incorrect details will cause claim rejection, and invoices will be sent directly to you.MEMBERSHIP / POLICY NUMBERCONFIRM MEMBERSHIP / POLICY NUMBERAUTHORISATION CODE CONFIRM AUTHORISATION CODE NUMBER OF APPROVED TREATMENTSUPPER PAYMENT LIMIT (£)MEMBER’S SESSION CONTRIBUTION (%)BODY PART- Select -Head / NeckShoulder / Upper ArmElbow / ForearmWrist / HandBackHip / GroinUpper LegKneeLower LegFoot / Ankle I confirm all details match my insurance policy exactly. If any information is incorrect or incomplete, I will be responsible for all charges. ➡️ Click ‘Next’, you’re almost there.PreviousNextConfirm Your Policy ExcessKnowing your excess now means you won't incur any unexpected charges. Your excess is the amount you’ve agreed to pay personally before your insurer starts covering your treatment costs. For example, if your excess is £100, you’ll cover this first £100 yourself, and then your insurer will pay the rest.CONFIRM YOUR EXCESS I confirm that I am responsible for covering any excess, unpaid invoices, or shortfalls not covered by my insurer.FAQ & SupportImportant Confirmation Please confirm that you understand you will be responsible for any shortfall not paid by your private medical insurance provider. This may include: Insurance policy excess Unpaid invoices Treatment session underpayments What is an insurance excess? An excess is your agreed contribution toward treatment costs. It’s set when you take out your insurance — usually between £50 and £250 — and applies once per policy year. How do I find out my excess? You can check this quickly by logging into your insurer’s online portal or calling them directly. Most clients find out in under 5 minutes. How do I pay my excess, unpaid invoices, or shortfalls not covered by my insurer? If any invoices are unpaid or there is excess to pay, we’ll send you a secure payment SMS link to settle the balance.➡️ Click Next finalise your booking.PreviousNextYour Personal Details⚠️ Your details must match your insurance policy exactly. Incomplete or incorrect details (e.g. nicknames or missing street name or postcode) will cause claim rejection, and invoices will be sent directly to you.TITLE- Select -MsMissMrDrProfMxSirDameRevFrRabbiImamPastorLordLadyFIRST NAMEMIDDLE NAMELAST NAMEDATE OF BIRTHEMAILPHONE NUMBERYOUR ADDRESSAddress Line 1Address Line 2CityState / ProvinceZIP / Postal codeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)RomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe I confirm all details match my insurance policy exactly. If any information is incorrect or incomplete, I will be responsible for all charges.PreviousNextConsent to ProceedBy undergoing treatments, you give explicit consent for One Body LDN to communicate with your GP, consultant, or private medical insurance company if needed, for the purpose of requesting further treatment sessions or discussing relevant medical information in your best interests. I confirm I give consent for One Body LDN to liaise with my GP, consultant, or insurer regarding my treatment when necessary. Previous Submit Health Insurance Form (#11) IntroAuthorisationInsurance Cover ActivationPersonal & Session DetailsConfirmation Activate Your Health Insurance FastWe guide you through, step-by-step.Fill this in once - and we’ll handle everything else.Most clients complete this in under 10 minutes and get their treatment costs covered.Click ‘Next’ to choose your insurer and follow the quick call script.PreviousNextTakes ~10 minGet Your Authorisation CodeDue to GDPR, only you can complete this step. But don't worry, most clients get their code in under 10 minutes. If you have more than one area of pain or tightness — for example, back and knee — request another authorisation code. That way, you’ll get: 5 sessions for your knee, plus 5 sessions for your back = 10 total sessions, instead of sharing one block across both areas. It takes the same amount of time to ask - yet yields double the benefit.Choose Your Insurer Below Select your insurer to view your step-by-step guide, which includes call scripts, phone numbers, and links to instantly retrieve your code. Once you’ve got your code(s), you enter them on this same form, and we’ll take care of the rest.INSURER- Select -AetnaAllianzAXAAXA Global / AXA InternationalAvivaBupaBupa Global / Bupa InternationalCignaCigna Global / Cigna InternationalHCMLHealixVitalityWPAOtherPreviousChoose Your InsurerTakes ~ 5 minHow to Get Your Authorisation CodeStep 1: Call AetnaCall the number on your Aetna ID card first — that’s your quickest route to an authorisation code. If you don’t have your card: call +44 800 085 2596 (Aetna International UK) or +44203 680 5200 (Aetna Global Benefits UK) Make sure to have your membership number ready when you call.Step 2: Use This Script (Read It Out)“Hi, I’d like to authorise physiotherapy treatment for my [PAIN/TIGHTNESS/INJURY]. My name is [Your Full Name], my DOB is [DD/MM/YYYY], and my physio is One Body LDN. Can you please issue me a pre-authorisation code?” Most clients get their code during this first call. ⚠️ Important: Make Sure They Link You to One Body LDN Tell them: Provider Number: SP074886 Clinic: One Body LDN This ensures your authorisation is connected to us correctly.➡️ Click ‘Next’ to send us your details, it’s plain sailing from here.Takes ~ 5 minHow to Get Your Authorisation Code📞 Step 1: Call AllianzCall the number on your Allianz card first. If you don’t have it, try +44 20 8603 9653 (Allianz Assistance UK). Make sure to have your membership number ready when you call.🗣️ Step 2: Use This Script (Read It Out)“Hi, I’d like to authorise physiotherapy treatment for my [PAIN/TIGHTNESS/INJURY]. My name is [Your Full Name], my DOB is [DD/MM/YYYY], and my physio is One Body LDN. Can you please issue me an authorisation code?” Most clients receive their code instantly on this call. ⚠️ Important: Make Sure They Link You to One Body LDN Give Allianz these details: Your Physiotherapist’s Name Provider Number - 6380984 Clinic: One Body LDN This ensures your authorisation is correctly assigned to us so your sessions are covered.➡️ Click ‘Next’ to send us your details, it’s plain sailing from here.Takes ~ 5 min How to Get Your Authorisation Code📞 Step 1: Call AXACall the number on your AXA card first or sign in to your AXA Health account. If you don’t have the card: AXA Health members may call +44 345 600 4461 (or +44 800 169 7593). For AXA Global Healthcare provider authorisations, call +44 1892 503 856 or email icmtgeneral.health@axa.com. Make sure to have your membership number ready when you call.🗣️ Step 2: Use This Script (Read It Out)“Hi, I’d like to authorise physiotherapy treatment for my [PAIN/TIGHTNESS/INJURY] with my provider. My name is [YOUR NAME], DOB is [YOUR DATE OF BIRTH], and my physiotherapy clinic is One Body LDN. Can you please issue me an authorisation code?” Most clients receive their code instantly during this call. ⚠️ Important: Make Sure They Link You to One Body LDN Give AXA these details: Clinic: One Body LDN Clinic AXA Provider Number: can be found here This ensures your authorisation is correctly assigned to us so your sessions are covered.➡️ Click ‘Next’ to send us your details, it’s plain sailing from here.Takes ~ 5 min How to Get Your Authorisation Code📞 Step 1: Call AXA GlobalCall the number on your AXA card first. If you don’t have it, call +44 1892 503 856 (AXA Global Healthcare — provider/pre-authorisation) or +44 203 4995 487 (member callback). Or log in to your online account Make sure to have your membership number ready when you call.🗣️ Step 2: Use This Script (Read It Out)“Hi, I’d like to authorise physiotherapy treatment for my [PAIN/TIGHTNESS/INJURY] with my provider. My name is [YOUR NAME], DOB is [YOUR DATE OF BIRTH], and my physiotherapy clinic is One Body LDN. Can you please issue me an authorisation code?” Most clients receive their code instantly during this call. ⚠️ Important: Make Sure They Link You to One Body LDN Give AXA Global these details: Clinic: One Body LDN Clinic AXA Provider Number: can be found here This ensures your authorisation is correctly assigned to us so your sessions are covered.➡️ Click ‘Next’ to send us your details, it’s plain sailing from here.Takes ~ 5 min How to Get Your Authorisation Code📞 Step 1: Call Aviva InsuranceCall the number on your Aviva card first. If you don’t have it, call +44 800 068 3827 to request an authorisation code. Make sure to have your membership number ready when you call.🗣️ Step 2: Use This Script (Read It Out)“Hi, I’d like to authorise physiotherapy treatment for my [PAIN/TIGHTNESS/INJURY]. My name is [Your Full Name], my DOB is [DD/MM/YYYY], and my physio is One Body LDN. Can you please issue me an authorisation code?” Most clients receive their code instantly on this call. ⚠️ Important: Make Sure They Link You to One Body LDN With Aviva, we are registered under individual therapists (not “One Body” as a single clinic). Give Aviva these details: Your Physiotherapist’s Name Therapist Provider Number: can be found here Clinic: One Body LDN This ensures your authorisation is correctly assigned to us so your sessions are covered.➡️ Click ‘Next’ to send us your details, it’s plain sailing from here.Takes ~ 5 min How to Get Your Authorisation Code📞 Step 1: Call BupaCall the number on your Bupa ID card first. If you don’t have it, call +44 345 609 0111 (Bupa member services) to request an authorisation code for physiotherapy. Make sure to have your membership number ready when you call.🗣️ Step 2: Use This Script (Read It Out)“Hi, I’d like to authorise physiotherapy treatment for my [PAIN/TIGHTNESS/INJURY] with my provider. My name is [Your Full Name], my DOB is [DD/MM/YYYY], and my physio is One Body LDN. Can you please issue me an authorisation code?” Most clients receive their code instantly during this call. ⚠️ Important: Make Sure They Link You to One Body LDN Tell them: Provider Number: 80013606 Clinic: One Body LDN This ensures your authorisation is connected to us correctly. Bupa Claim Help Page➡️ Click ‘Next’ to send us your details, it’s plain sailing from here.Takes ~ 5 min How to Get Your Authorisation Code📞 Step 1: Call Bupa InternationalFor Bupa Global / International plans, call the number on your Bupa Global card first. If you don’t have it, call +44 1273 323 563 (Bupa Global provider/pre-authorisation) or +44 1273 333 911 (24-hour Medical Centre). Alternatively, use the Bupa Global MembersWorld App: Login here🗣️ Step 2: Use This Script (Read It Out)“Hi, I’d like to authorise physiotherapy treatment for my [PAIN/TIGHTNESS/INJURY]. My name is [Your Full Name], my DOB is [DD/MM/YYYY], and my physio is One Body LDN. Can you please issue me a pre-authorisation code?” Most clients get their code instantly. ⚠️ Important: Make Sure They Link You to One Body LDN Give Bupa International these details: Your Physiotherapist’s Name - State that they are “HCPC registered” Clinic Provider Number – 651474 Clinic: One Body LDN Alternative: Pre-Authorisation via the App If you prefer, log into MembersWorld to request authorisation online. Once approved, you’ll receive a pre-authorisation code to use for your physiotherapy sessions. Remember the Validity Pre-authorisations are valid for 31 days. They begin either on the treatment start date or on the issue date (if no treatment date has been set yet). Bupa International Claim Help➡️ Click ‘Next’ to send us your details, it’s plain sailing from here.Takes ~ 5 min How to Get Your Authorisation Code📞 Step 1: Call CignaCall the number on your Cigna ID card first. If you don’t have your card, call +44 1475 788 182 (Cigna Global/Customer Care). For some international plans, try the global toll-free line +800 253 7052 0 Make sure to have your membership number ready when you call.🗣️ Step 2: Use This Script (Read It Out)“Hi, I’d like to authorise physiotherapy treatment for my [PAIN/TIGHTNESS/INJURY]. My name is [Your Full Name], my DOB is [DD/MM/YYYY], and my physio is One Body LDN. Can you please issue me an authorisation code?” Most clients get their code instantly during this call. ⚠️ Important: Make Sure They Link You to One Body LDN Give Cigna these details: Your Physiotherapist’s Name Therapist Provider Number: can be found here Clinic: One Body LDN This ensures your authorisation is correctly assigned to us so your sessions are covered. Cigna Claim Help Page ➡️ Click ‘Next’ to send us your details, it’s plain sailing from here.Takes ~ 5 min How to Get Your Authorisation Code📞 Step 1: Call Cigna InternationalFor Cigna Global / International plans, call the number on your card. If missing, call +44 1475 788 182 or +44 1475 333 403 (Cigna Global customer care/provider help). Make sure to have your membership number ready when you call.🗣️ Step 2: Use This Script (Read It Out)“Hi, I’d like to authorise physiotherapy treatment for my [PAIN/TIGHTNESS/INJURY]. My name is [Your Full Name], my DOB is [DD/MM/YYYY], and my physio is One Body LDN. Can you please issue me an authorisation code?” Most clients get their code instantly during this call. ⚠️ Important: Make Sure They Link You to One Body LDN Give Cigna International these details: Your Physiotherapist’s Name - State that they are “HCPC registered” Clinic: One Body LDN This ensures your authorisation is correctly assigned to us so your sessions are covered.➡️ Click ‘Next’ to send us your details, it’s plain sailing from here.Takes ~ 5 min How to Get Your Authorisation Code📞 Step 1: Call HCML HCML doesn’t allow patients to self-refer. Your insurer, solicitor, employer, or case manager needs to submit your referral online or by phone. This referral can be made online through HCML's website. If your insurer asks you to contact HCML for rehabilitation or triage, call: +44 333 023 0155 (HCML Back to Better) +44 20 8649 8006 (general HCML enquiries) 🗣️ Step 2: Complete Your Digital Assessment Once referred, HCML will send you a unique link to access their online platform. Fill out the short online form about your pain, tightness, or injury. Most clients finish this step in under 5 minutes.Book Your Physiotherapy at One Body LDNHCML will provide a tailored plan that may include self-help exercises, online treatment, or face-to-face physiotherapy sessions. If face-to-face treatment is approved, you’ll be able to choose your preferred clinic. Select One Body LDN to ensure your sessions are covered and booked seamlessly. HCML Physiotherapy Info➡️ Click ‘Next’ to send us your details, it’s plain sailing from here.Takes ~ 5 min How to Get Your Authorisation Code📞 Step 1: Call HealixCall the number on your Healix ID card first. If you don’t have it, call Healix Main Reception +44 20 3376 3905 or Healix Healthline +44 20 8481 7800 for provider/pre-authorisation assistance. Make sure to have your membership number ready when you call.🗣️ Step 2: Use This Script (Read It Out)“Hi, I’d like to authorise physiotherapy treatment for my [PAIN/TIGHTNESS/INJURY]. My name is [Your Full Name], my DOB is [DD/MM/YYYY], and my physio is One Body LDN. Can you please issue me an authorisation code?” Most clients receive their code instantly on this call. ⚠️ Important: Make Sure They Link You to One Body LDN Give Healix these details: Your Physiotherapist’s Name Therapist Provider Number: can be found here Clinic: One Body LDN This ensures your authorisation is correctly assigned to us so your sessions are covered.➡️ Click ‘Next’ to send us your details, it’s plain sailing from here.Takes ~ 5 min How to Get Your Authorisation Code⚠️ Vitality often tries to send members to one company called Ascenti. But Ascenti is only their preferred provider because they are cheaper. You are fully entitled to choose One Body LDN and be seen "out of network" instead. We still honour Vitality's £35 rate and are fee assured, with no extra cost to you.📞 Step 1: Call VitalityCall the number on your Vitality ID card first. If you don’t have it, call Vitality Health (existing members) on +44 345 602 3523 or use the Vitality Member Zone / Care Hub to request physiotherapy authorisation. Make sure to have your membership number ready when you call.🗣️ Step 2: Use This Script (Read It Out)“Hi, I’d like to authorise physiotherapy treatment for my [PAIN/TIGHTNESS/INJURY]. My name is [Your Full Name], my DOB is [DD/MM/YYYY], and my physio is One Body LDN. Can you please issue me an authorisation code?” Tip: Always describe your issue as a recent pain or injury. Vitality will not cover long-standing or pre-policy issues. Most clients get their code instantly during this call. ⚠️ Important: Make Sure They Link You to One Body LDN ⚠️ Vitality often tries to send members to one company called Ascenti. You are fully entitled to choose One Body LDN instead at no extra cost. All our therapists are fee-assured at £35 per session, so you will never pay extra (unless your policy has an agreed-upon excess). Give Vitality these details: Your Physiotherapist’s Name Therapist Provider Number: can be found here Clinic and post code: can be found on the relevant clinic location pages on our website This ensures your authorisation is correctly assigned to us so your sessions are covered.➡️ Click ‘Next’ to send us your details, it’s plain sailing from here.Takes ~ 5 min How to Get Your Authorisation Code📞 Step 1: Call WPACall the number on your WPA ID card first. If you don’t have it, call WPA member services: +44 182 362 5230 (personal/member enquiries) or +44 182 362 5000 for general office/provider contact. Make sure to have your membership number ready when you call.🗣️ Step 2: Use This Script (Read It Out)“Hi, I’d like to authorise physiotherapy treatment for my [PAIN/TIGHTNESS/INJURY] with my provider. My name is [YOUR NAME], DOB is [YOUR DATE OF BIRTH], and my physiotherapy clinic is One Body LDN. Can you please issue me an authorisation code?” Most clients receive their code instantly during this call. ⚠️ Important: Make Sure They Link You to One Body LDN Give WPA these details: Your Physiotherapist’s Name Therapist Provider Number: can be found here Clinic: One Body LDN This ensures your authorisation is correctly assigned to us so your sessions are covered.➡️ Click ‘Next’ to send us your details, it’s plain sailing from here.Takes ~ 5 min How to Get Your Authorisation CodeNo matter who your provider is, activating your cover is quick and easy.⚠️ Important: If You Have a “Cashback” Health SchemeIf you’re with Health Shield, Simplyhealth, Westfield Health, Paycare, or BHSF, you don’t need pre-authorisation. These are cashback schemes — that means: You simply book and pay for your session with us (as normal). We’ll send you an itemised receipt for your physiotherapy session after the appointment. You send this to your cashback provider, and they reimburse you directly — usually within a few days. Most clients get their money back fast and with zero hassle. Book Your Cashback Sessions HereStep 1 – Contact Your Insurer Calling your insurer’s customer service line (the number is usually on the back of your policy card or app) or Log in to your online member portal — many insurers have a “Make a Claim” or “Pre-authorisation” section. 🗣️ Step 2: Use This Script (Read It Out)“Hi, I’d like to authorise physiotherapy treatment for my [PAIN/TIGHTNESS/INJURY]. My name is [Your Full Name], my date of birth is [DD/MM/YYYY], and my provider is One Body LDN. The physiotherapists at One Body LDN are HCPC registered. Can you please issue me an authorisation or claim reference?” Most insurers can issue your code or approval instantly during this call.➡️ Click ‘Next’ to send us your details, it’s plain sailing from here.PreviousNext Enter Your Details to Activate Your Insurance Cover ⚠️ Your details must match your insurance policy exactly. Incorrect details will cause claim rejection, and invoices will be sent directly to you.MEMBERSHIP / POLICY NUMBERCONFIRM MEMBERSHIP / POLICY NUMBERAUTHORISATION CODE CONFIRM AUTHORISATION CODE NUMBER OF APPROVED TREATMENTSUPPER PAYMENT LIMIT (£)MEMBER’S SESSION CONTRIBUTION (%)BODY PART- Select -Head / NeckShoulder / Upper ArmElbow / ForearmWrist / HandBackHip / GroinUpper LegKneeLower LegFoot / Ankle I confirm all details match my insurance policy exactly. If any information is incorrect or incomplete, I will be responsible for all charges. ➡️ Click ‘Next’, you’re almost there.PreviousNextConfirm Your Policy ExcessKnowing your excess now means you won't incur any unexpected charges. Your excess is the amount you’ve agreed to pay personally before your insurer starts covering your treatment costs. For example, if your excess is £100, you’ll cover this first £100 yourself, and then your insurer will pay the rest.CONFIRM YOUR EXCESS I confirm that I am responsible for covering any excess, unpaid invoices, or shortfalls not covered by my insurer.FAQ & SupportImportant Confirmation Please confirm that you understand you will be responsible for any shortfall not paid by your private medical insurance provider. This may include: Insurance policy excess Unpaid invoices Treatment session underpayments What is an insurance excess? An excess is your agreed contribution toward treatment costs. It’s set when you take out your insurance — usually between £50 and £250 — and applies once per policy year. How do I find out my excess? You can check this quickly by logging into your insurer’s online portal or calling them directly. Most clients find out in under 5 minutes. How do I pay my excess, unpaid invoices, or shortfalls not covered by my insurer? If any invoices are unpaid or there is excess to pay, we’ll send you a secure payment SMS link to settle the balance.➡️ Click Next finalise your booking.PreviousNextYour Personal Details⚠️ Your details must match your insurance policy exactly. Incomplete or incorrect details (e.g. nicknames or missing street name or postcode) will cause claim rejection, and invoices will be sent directly to you.TITLE- Select -MsMissMrDrProfMxSirDameRevFrRabbiImamPastorLordLadyFIRST NAMEMIDDLE NAMELAST NAMEDATE OF BIRTHEMAILPHONE NUMBERYOUR ADDRESSAddress Line 1Address Line 2CityState / ProvinceZIP / Postal codeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)RomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe I confirm all details match my insurance policy exactly. If any information is incorrect or incomplete, I will be responsible for all charges.PreviousNextConsent to ProceedBy undergoing treatments, you give explicit consent for One Body LDN to communicate with your GP, consultant, or private medical insurance company if needed, for the purpose of requesting further treatment sessions or discussing relevant medical information in your best interests. I confirm I give consent for One Body LDN to liaise with my GP, consultant, or insurer regarding my treatment when necessary. Previous Submit
