Application Form

We are delighted to open our new online booking system!

Please select which dates you would like to book and fill in all the required fields.

All bookings normally run from Saturday to Friday. If we can, we shall do out best to accomodate alternative requests.

Once we recieve your booking details, we shall confirm if your booking application has been successful.
We look forward to welcoming you to stay at Eilidh Brown’s.
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Primary Care Giver*:

Address*:

Postcode*:

Telephone Number*:

Email*:

Car Reg Number*:

Child's name*:

Amount of Children Staying*:

Child 1 Age:

Child 2 Age:

Child 3 Age:

Child 4 Age:

Are they currently undergoing active treatment (Please select 'Yes' or 'No')*:

If No, When Did They Receive Their Last Treatment?:

Consultant Name*:

Consultant Address*:

Consultant Postcode*:

Consultant Telephone Number*:

Consultant Email*:

Consultant Hospital*:

Nurse Name*:

Nurse Address*:

Nurse Postcode*:

Nurse Telephone Number*:

Nurse Email*:

Nurse Hospital*:

Do You Agree To The Terms & Conditions? (Please select 'Yes' or 'No')*:

Keeping in touch

Please let us know how you wish to be contacted, you can change this at any time. Likewise, please do let us know if your contact details change. If you change your mind about any of these choices or have any concerns about any communications from us, please contact info@eilidbrown.co.uk. Your information will be held securely and confidentially in line with our Privacy Policy, available at www.eilidhbrown.co.uk/privacypolicy. I am happy for my data to be used to contact me about: (tick all that apply)

 

 

 

I am happy to be contacted via: (tick all that apply)