- About You
Health Needs Assessment Form
Please complete the form below if
- You would like us to arrange an e‑consultation for you, or
- You would like to come to the UK for medical treatment.
Please provide as much relevant medical information as possible.
Once we receive your completed form, we will contact you within 24 hours.
Tell us a bit about yourself
* We comply with the European Union’s General Data Protection Regulation (GDPR). Please see
Tell us about your health problem
Please provide details of your diagnosis.
Please provide your doctor/surgeon's address.
Please provide details of any treatments you have had to date.
Tell us about your medical history
Have you ever had any of the following?