Concierge Care - Membership Registration Form

Concierge Care - 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 Concierge Care Membership
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Concierge Care Membership - Monthly Payment
By subscribing to Concierge Care for £149 per month, you will receive the following benefits: • Annual Health Check for Adults: A 30-minute Home Visit 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 thereafter. • Comprehensive Blood Test for Adults: A blood test included as part of your annual health check to assess your overall health. • 10 GP Home Visits per Year: You are entitled to 10 home visits from a GP per year for convenient, personalised care. • 5 Telephone Consultations per Year: You will have access to 5 telephone consultations with a GP each year. • 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 blood tests.

£149.00 for each month
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