This form collects your name, email and contact details. We will ask for your consent to collect this information, and separately for how we may contact you. Check our Privacy Policy for information about how we store, protect and manage your submitted data. We are unable to accept form submissions without express consent from you in the checkbox below, as per the new data protection regulations (GDPR).

I am 18 or older and I consent to having Reverse Time Ltd collect my details, store and use my information in the manner described above.

Please add me to your newsletter list for updates and new services.DO NOT add me to your newsletter list for updates and new services

Please contact me by the method(s) selected below:

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Not being able to contact you either by email or phone will hinder our ability to contact you or provide you with clinically relevant responses in a timely manner.

Knowing that I can opt-out and change my preferences, I consent to receive relevant notifications:

Important notifications only - clinic hours, appointment scheduling and reminders
General promotions - monthly informational newsletter.Product and service information - treatment offerings.Promotional offers - contests, offers on non-prescription treatments.Patient education literature.Other ad-hoc occasional mailings.

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