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0207 971 1787
Fertility Testing
Joint injections
GP consultations
Tests and scans
Health screening
Sexual health
Vaccines
Ear wax removal
Covid-19
Cryotherapy & wart removal
Weight Loss
Contraception coil options
Dental check-up
Invisalign
Smile makeover
Hygienist
Orthodontics
Dental implants
Teeth whitening
Child Specialists
Paediatrician
Child assessments
Skin Clinic
Mole Checks
General Dermatology
Facial Aesthetics
Minor Skin Surgery
Minor Skin Surgery Treatments
Dermal Fillers
Anti-wrinkle injections
Chemical skin peel
Pigmentation & Acne Treatment
Mental health
Physiotherapy
Medical insurance
Diet and nutrition
Podiatry
Gynaecology
Dental
Proactive private Dental & Hygiene care for a healthy smile
Adult - £25 / month
Child - £10 / month
GP
Personal private GP always on hand for you & your family
Adult - £35 / month
Complete
Combine our Dental & GP plans for comprehensive proactive healthcare
Adult - £45 / month
Child - £15 / month
Premium
Perfect for complete peace of mind - with advanced medical & dental care
Adult - £65 / month
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Your journey starts with completing a questionnaire that will be reviewed by one of our GPs. Please complete the information as accurately as possible, so we can assess your suitability for our programme.
The information you submit is safe. Data you send via this form is encrypted and is stored securely on MyHealthcare Clinic servers. Remember, your responses will be kept confidential.
Your details
Your contact details
Date of birth
Please indicate preferred contact method
What measurement would you like to use?
cm and kgft and stone
What is your height in cm?
What is your height in feet and inches?
What is your current weight in kg?
What is your current weight in stone and pounds?
What sex were you assigned at birth?
FemaleMale
Are you pregnant, breastfeeding or trying for a baby?
Please note that our treatment programme is not suitable for use while breastfeeding, pregnant, or currently trying for a baby.
PregnantBreastfeedingActively trying for a babyPlanning to conceive in the next 3 monthsNone of the above
What is your ethnic background?
White (Caucasian)Asian (including Indian subcontinentBlack African or African-CaribbeanMiddle EasternLatino / HispanicNot listed
How would you rate your physical fitness?
Very goodGoodAdequatePoor
How many hours of physical activity do you do per week?
eg. gym, running, swimming or team sports
More than 7.5 hours5 - 7.5 hours2.5 - 5 hoursLess than 2.5 hours
Have you been diagnosed with or experienced any of the following?
Please choose all that apply
Do you take any medications?
YesNo
Have you ever taken any medication for weight loss?
Do you have any allergies?
How would you rate your mood in the last 2 weeks?
GoodNeutralLow
Please select any that are true for you
Would you like to inform your GP about this treatment?
Please share the name of your GPs surgery
By submitting this form, you agree with the storage and handling of your data by our team. Please wait for the form to refresh after pressing submit.
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Reception Team
