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GP Details

If unsure of all GP contact information please enter just name of surgery

Referral Source

Data Sharing and Protection

COVID-19 Health Declaration

For the safety of all visitors, patients, and staff it is important that we ask you the following questions and you answer honestly. If you answer YES to any of the following questions then please get in touch with our customer care team as soon as possible and DO NOT come to the clinic. we appreciate your understanding and co-operation in this matter.

Equal Opportuniy Monitoring

We are committed to providing services that meet the needs of all members of our community. Your responses to the questions below will help us to monitor the diversity of people using our services as well as their experiences of our services and will help to inform our planning for the future. This information is anonymous and will not be used for any other purposes.

Declaration of Consent

By signing this form you are agreeing to all terms and conditions without any reservation, please tick the box below to confirm this and there is a link to full terms and conditions.

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