Dear Patients: Please Complete This Medical History Form

IMPORTANT
Unfortunately, we do not provide NHS treatment for new patients.
Please only fill-in the form below once you have spoken to Sophie from our reception team on 020 8542 3554

• Your information will be collected securely as per GDPR guidance and is GDPR compliant
• You may request a copy in-clinic as we will not send an email copy to ensure the protection of your personal data
• Once your form is submitted you will receive a reference number. Please take note of this as it may be required in-clinic