Please print out this form, complete it, and fax to Doreen & Peter Trust at 
    the Disfigurement Guidance Centre on:
     +44 (0) 1337 870310  DGC, PO BOX 7, Cupar, Fife KY15 4PF, Scotland

Clinic Name:
Head of Clinic: 
Address :

 

Telephone:   
Fax:  
Lasers:

 

Treatments:

 

General Anaesthesia?:  
Clinicians: 
e-mail:  
web site:     http://www.


Signature of Head of Clinic to verify this information .......................................

Print  name:                                                                Date: