Name *

First Name

Last Name

Date Of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

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These questions help us understand your condition and whether treatment is suitable. Please answer honestly and in your own words where possible. *

Are you experiencing any of the following symptoms?

Pain

Itching

Bleeding

Swelling

Lump

Discomfort when passing stools

None of these

Consent & Declaration *

I confirm that the information provided is accurate and complete.

I understand that this service is not a replacement for in-person NHS care.

I understand that certain symptoms may require referral to my GP.

I consent to this information being used to assess my suitability for treatment.