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Health Review Questionnaire

To assist your Health Review with us, we ask that you please complete this questionnaire as fully as possible.

Please tick below or specify, if other

Mr
Mrs
Miss
Ms
Other

Other, please specify

First/Last Name(s) *

Date of Birth

Address

Mobile Telephone Number

Email Address *

Do you suffer from any existing medical conditions?

Are you currently on any medication?

Do you consent to us informing your GP, if felt appropriate in the event of any significant results or findings?

Yes (GP)
No (GP)

If yes, please complete the information below with your GP's details:

Name

Address

Telephone number

Email Address

We recognise that when you provide us with personal information you are trusting us to take good care of it. Please refer to our Privacy Policy for more information about how we collect, use, and protect your data.

Please tick below

Cholesterol Test - £25
Glucose Test - £25
Urine Test (For Infections) - £25
Early Pregnancy Test - £25
Blood Group Test - £27
Menopause Test - £27
Stomach Ulcer Test - £27
Prostate Test - £28
Gluten Test (Coeliac Test) - £29
Vitamin D Test - £29
Iron Test (For Tiredness) - £29
Thyroid Test - £29
Strep A Test - £29
IgE Test (For Allergies) - £29
Covid Antibody Test - £49
HbA1c Rapid Quantitative Test - £89
T4 Rapid Quantitative Test - £89
Thyroid Stimulating Hormone (TSH) Test - £89
Progesterone Rapid Quantitative Test - £120
Follicle Stimulating Hormone (FSH) Test - £120
Luteinising Hormone (LH) Test - £120
Testosterone Rapid Quantitative Test - £120
PSA Rapid Quantitative Test - £120

I consent to a blood sample being taken from my finger to see whether the test/s I have indicated above are positive or negative.

Signature *

Date *

IMPORTANT NOTE: Our tests are not a substitute for seeing your Doctor, especially if you are suffering symptoms. We will interpret your results based on National Guidelines. You will be advised to see your Doctor for any follow-up action.

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Each health screening test is carried out by a pharmacist taking a finger prick of blood from your finger. The blood is then placed in a device or machine. The results will then be interpreted by the pharmacist and advice & guidance given. In the majority of cases the results take 10 minutes.

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