Couple Plan - Membership Registration Form

Couple Plan - Membership Registration Form

Please enter details of 1 adult from the couple - we will contact you to get the additional adult registered as a member
Patient Details:
Full Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
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
Sign-up for Couple Plan Membership
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Couple Plan Membership - Monthly Payment
By subscribing to the Couple Plan for £109 per month, you will receive the following benefits, which cover 2 adults:

• Annual Health Check for Each Adult: 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 thereafter.

• Comprehensive Blood Test for Each Adult: A blood test included as part of your annual health check to assess your overall health.

• 16 Face-to-Face or Remote GP Appointments per Year: You are entitled to a total of 16 GP consultations per year, which can be shared between both adults. These appointments can be used for any medical concerns.

• Free Repeat Prescriptions: You will receive repeat prescriptions at no additional charge for both members, 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.

£109.00 for each month
Should be Empty:

Couple Plan - Membership Registration Form

Sign-up for Couple Plan Membership