Detox Enquiry Form
Please do not leave any boxes blank. Enter "none" or "OK" etc. as appropriate.
 
Your contact details
 
Name 
Date of Birth      
Address 
Post Code
Telephone 
Fax
Mobile 
E-mail address 
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Your health
 
GP's Name 
GP's Telephone 
Surgery Address
(with postcode) 
Known mental health problems 
Liver disease 
Heart disease 
Brain disease
(including epilepsy or history of fits) 
Respiratory disease 
Other general physical health problems 
Any current prescribed medications 
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Detox Anonymous
If you believe that you have an addiction and you are really committed to recovery call 0845 450 3977