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Patient Questionnaire...

Before you come and visit us, please provide some initial information

We are a Private Clinic and a sample of our charges is listed within our Pricelist accessed from the home page immediately below the section for registration.

Please try to answer the questions below as honestly as possible. The answers will help us provide the best care for you. These notes will never be released to any other person in any form without your express written permission. You can request a copy of all information we hold on you at any time. Remember you can leave any question you are uncomfortable with blank.

Please bear in mind that you will have been quoted a basic consultation fee to see the doctor or therapist. Sometimes blood tests or other procedures may attract extra fees and we want you to be clear about this to avoid a nasty shock! Typical costs of blood tests include HIV £50; syphilis £45 and swabs £40-65. Other test prices are available on request. We use the Doctors Laboratory.

Please download our consultation form, and please complete before arriving at the clinic. click here to download

Consultation date
First Name*
Surname
Gender   
DOB (dd/mm/yyyy)*
Address (line 1)
Address (line 2)
Town / City
Country
Postcode
Email
Mobile
Work Telephone
Would you like to receive updates from Freedomhealth?
Can we contact your GP?
If yes, please give their address
Are you taking any medications?
If yes, what are they?
Have you been immunised against Hepatitis A and/or B?
Do you have any allergies to medications?
If yes, what are they?
Have you ever been in hospital?
If yes, what for?
Do you know your HIV status?
If yes, what is it?
If positive, can we know which clinic you attend and your doctor?
Clinic:
Doctor's name:
Have you ever had cosmetic surgery, including Botox, dermal fillers, hair transplant?
What's your job?
Do you smoke?
Do you drink alcohol?
How did you hear about us?*
What do you think of out website?
Could be improved by...
  * required information

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60 Harley Street, London, W1G 7HA | T: 020 7637 1600 F: 020 7612 2509 | Mon-Fri 8.30am-6.00pm Sat 10.30am-3.30pm | info@freedomhealth.co.uk

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