Enquiry Form - drmusasami.co.uk

Step 1 of 4 — About You

Let's start with you

Who is this enquiry for? (required)

Dr Musa Sami currently sees adult patients only. If you are enquiring for another adult, please provide the patient's own direct contact details where possible.

Full name (required)

Age (required)

Gender (optional)

Your full name (required)

Your relationship to the patient (required)

Patient's full name (required)

Patient's age (required)

Patient's gender (optional)

Where are you based? (required)

Dr Sami currently sees patients based in the UK only. You're welcome to submit an enquiry and we'll advise accordingly.

How can we help?

What would you like help with? (select all that apply)

ADHD / attention difficulties Anxiety Depression Stress or burnout Trauma / PTSD Mood changes Not sure / need assessment

Have you received support before? (required)

How urgent does this feel? (required)

Anything you'd like Dr Musa to know? (optional)

How did you hear about us? (optional)

How should we reach you?

Email address (required)

Phone / WhatsApp (required)

Include your country code if outside the UK.

We only call when you're expecting it — no unexpected calls.

Preferred contact method (required)

Your email address (required)

Your phone / WhatsApp (optional)

Patient's direct email address

Patient's direct phone / WhatsApp

Include country code if outside the UK.

Please provide at least one direct contact method for the patient where possible.

Preferred first contact method for the patient (required)

Almost done

Summary of your enquiry:

Patient name:

Looking for help with:

Preferred contact:

🔒 Your information is confidential and handled securely

This is not a diagnosis — this is an initial enquiry only

I agree to be contacted regarding this enquiry

I confirm that the patient is aged 18 or over and has consented to me making this enquiry on their behalf

I understand that confidential clinical information will only be shared directly with the patient unless explicit consent is provided

Responded to personally · No payment required · Confidential

Thank you — your enquiry has been received.

A member of the team will review your details and be in touch within one working day via the preferred contact method provided.

You don't need to do anything else at this stage.

If you have any questions in the meantime, you're welcome to email contact@drmusasami.co.uk.

Takes less than 2 minutes · No obligation

Let's start with you

How can we help?

How should we reach you?

Almost done

Thank you — your enquiry has been received.

Unit 5, Combo Park, Rear of 6 Bulwell Lane, Nottingham, NG6 0BT, Nottingham, United Kingdom

Reach out to me, talk to me, I’m listening!

contact@drmusasami.co.uk

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