The Slimming Doctor - Patient Medical Questionnaire

Patient Medical Questionnaire

The Information you provide will be treated in the strictest of confidence.
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Gender*

MaleFemale
Email Address*
example@example.com
Mobile Phone Number*
Please enter a valid mobile phone number
Landline Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

City

PostcodeCountry

BMI Calculator: What is your weight and height?*

Declaration and Consent
We will process your personal data (including sensitive or ‘special’ personal data in relation to your health) in accordance with our privacy policy.
Signature*

Clear
The Slimming Doctor is a trading name for Healthbase Limited, a company registered in England and Wales.
Registered number: 13418838. Registered office: 71-75 Shelton Street, London, WC2H 9JQ.
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