Your Medical History and enquiry

Your Medical History and enquiry

Please fill all relevant details below to help your medical assessment.
Please fill details of your illness and what you are hoping for ?*
List of all medicine you are currently taking *
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List all your medical conditions history below*
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Attach Photo of area if required. Please cover your face for privacy

Upload photo or relevant files
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Your Full Name*
Your Age:*
What is your gender?*
Your Phone number *
Email Address
example@example.com
Address for medicine delivery( If required)*

Street Address

City

Postal Code
Nearest Pharmacy , Name and post code (optional)
In case we need to send you medication online to your pharmacy.
Do you have any medication allergies?

YesNo
Consent
1. I agree to use onlline Health Care Services for evaluating, testing and diagnosing my medical condition.

2. I accept that the professionals can contact interactive sessions with video call, text message , whatsapp , phone consultation .

3. I understand that this is not replacement of my usual GP service . I agree to send reports to my Own GP if doctors deem necassary.

4. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.

5. I understand the risks and would contact 111 or go to emergency if my symptoms are not improving.
Signature

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Date

DayMonthYear
Date
Select Date and time which suits you .
Consultation Fee*
prevnext( X )
Private Medical Consultation Online/facetofaceThere no extra charged for prescription writing.
£70 Quantity

Home Visit ( Lancashire ) Pre Agreed Home visit request . Doctor will come to your address to see you as soon possible.
£150 Quantity

Total

£0.00
Should be Empty:

Your Medical History and enquiry

Consent