• About You
  • Diagnosis
  • Medical History
  • Review

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.

Please note that any personal information you submit to Metta Health will be held in the strictest of confidence according to our Privacy Policy*

Tell us a bit about yourself

Please provide your full name.
Please provide your date of birth.
Please provide your sex at birth.
Please provide the first line of your home address.
Please provide the second line of your home address.
Please provide your city.
Please provide your state.
Please provide your zip code.
Please provide your email address.
Please provide your phone number.
* We comply with the European Union’s General Data Protection Regulation (GDPR). Please see our Privacy Policy for more information.