Start Your Online ConsultationPlease complete the confidential form below, and our clinician will get back to you shortly! Patient Details * First Name Last Name Date of Birth * MM DD YYYY Gender * Male Female Address * Address 1 Address 2 City State/Province Zip/Postal Code Country NHS Number if known (###) ### #### Email * Phone * (###) ### #### GP Information * Are you registered with a GP? Yes No Would you like us to inform your GP? * Yes No Medical History * Do you have any medical conditions? If yes, please tell us, if not please enter n/a Do you take any regular medications * If yes, please tell us, if not please enter n/a Do you have any allergies? * If yes, please tell us, if not please enter n/a Consultation Reason * What are you seeking treatment for? Acne Urinary Tract Infection Weightloss Tonsillitis Cough/Chest infection Ear Infection Skin Infection Indigestion Pain Management Haemorrhoids Hayfever Mouth Ulcers Period Delay Bacterial Vaginosis Dental Abscess Medical Sick note Specialist Referral Repeat Prescription Other Describe your symptoms in as much detail as possible, any current diagnosis and how we can help * How did you hear about us? Option 1 Option 2 Consent & Declaration * I confirm the information provided is accurate I understand that this service is not a substitute for my GP I consent to my data being used for medical consultation I understand treatment is at the prescriber's discretion I am over 18 years old I give permission to access my Summary Care Record for the purpose of carrying out a safe and effective clinical check as part of my consultation Thank you for submitting your consultation form. We'll review your request. If a prescription is appropriate, we’ll be in touch