Clapham Common Clinic Gift Gift Voucher Post Form.

To buy a gift voucher by Cheque, Postal Order or Cash (registered post only). Complete and send this form to our address below. We will then send your voucher to your address.

Clapham Common Clinic
151/153 Clapham High Street
London
SW4 7SS
UK

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____    Cheque (UK£45.00 Payable to Clapham Common Clinic)
____    Postal Order (UK£45.00 only. Payable to Clapham Common Clinic)
____    Cash (Registered Mail UK£45.00 only)

Date: _____/________/________ 
clapham common clinic

Office use only;
Number:
Received:
  /     /
 Acknowledged:
E-Mail   Mail   Tel.

Details sent:
E-Mail   Mail   Tel.
  /     /

Title: Mr. Mrs. Miss Dr. Other:_________ 
Name: ______________________________ 
Telephone: ______________________________ 
Address: ______________________________ 
  ______________________________ 
  ______________________________ 
  ______________________________ 
Post/Zip Code: ______________________________ 
Country: ______________________________ 
E-mail: (please
print
clearly)___________________________________________

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