Signature Plan - Membership Registration Form

Signature Plan - Membership Registration Form
Patient Details:
Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Signature to accept terms of the membership agreement

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Sign-up for Signature Plan Membership
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Signature Plan Membership - Monthly Payment
By subscribing to the Signature Plan for £69 per month, you will receive the following benefits: Annual Health Check: A 30-minute face-to-face GP appointment for a comprehensive health check scheduled at any time within the first 12 months of your membership, with subsequent health checks scheduled every 12 months. Comprehensive Blood Test: A blood test included as part of your annual health check to assess your overall health. 10 Face-to-Face or Remote GP Appointments per Year: You are entitled to 10 face-to-face ore remote consultations with a GP each year, to address any medical concerns. Free Repeat Prescriptions: You will receive repeat prescriptions at no additional charge, as approved by a GP. Free Specialist Referrals: If necessary, you will be provided with free referrals to specialists for further care. 10% Discount on Additional GP Appointments and Investigations: You will receive a 10% discount on any additional GP consultations and further investigations, such as blood tests. 10% Discount on GP Appointments for Children Under 18: You will also receive a 10% discount on GP consultations for your children (under 18 years old) throughout your membership.

£69.00 for each month
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