Wellier – Client Request Form

1

What do you need today?* This field is required.

Pharmacist consultation

Doctor consultation or visit

Medication support & delivery

Clinical care

Other / not sure

2

Tell us about yourself.* This field is required.

your full name

your date of birth (e.g. date/month/year)

your mobile number (please enter your country code e.g. +44)

your email address

3

How soon do you need assistance?* This field is required.

Urgent — within 1–3 hours

Within 24 hours

At a preferred date or time

4

When would you like us to assist you?Please select your preferred date and time. We’ll do our best to arrange the closest available time and will confirm this with you directly.

5

Where should we assist you?* This field is required.Please select the location where you would like the service to take place.

Hotel

Home

Office

Other

6

Which hotel are you staying at?* This field is required.

Hotel name

7

What is your postcode?* This field is required.

e.g. SW1A 1AA

8

Is there anything else we should know?Please share only general information that may help us coordinate your request. Do not include medical history, symptoms, diagnoses, medication details or other sensitive health information here. Any medical information can be discussed directly with the appropriate healthcare professional. e.g. access instructions, hotel room details, preferred contact method or other practical information

9

By submitting this form, you acknowledge that Wellier will use the information provided to respond to and coordinate your request in accordance with our Privacy Notice.