Service Appointment Request Form
Full Name
*
First Name
Last Name
Phone Number
*
Format: (00000) 000-000.
E-mail
*
What date would you like your appointment ?
*
What time slot would you like?
*
Please Select
Morning 9am to 11am
Afternoon 11am to 1pm
Mid After-Noon 1pm to 4pm
Evening 4pm to 6pm
Which service would you like?
*
Please Select
Weight/Height (BMI) - PRIVATE £1
Blood Pressure - PRIVATE £2
BMI + Blood Pressure - PRIVATE £2.50
Glucose Reading + Blood Pressure + BMI - PRIVATE £7.50
Cholesterol + Blood Pressure + Glucose + BMI - PRIVATE £30
COPD/ Asthma Screening - PRIVATE £9.50
Erectile Dysfunction - PRIVATE From £25
Steps Ahead Diabetic Service - PRIVATE £30
Foot Care & Treatment - PRIVATE £25
Acupuncture - PRIVATE £35
Allergy Testing - PRIVATE From £75
Homeopathy - PRIVATE From £40
Hypnotherapy - PRIVATE From £60
Reflexology & Massages - PRIVATE From £25
Flu Vaccination - PRIVATE £12.50
Stop Smoking Programme - NHS Free*
EHC - Emergency Contraception - NHS Free*
Chlamydia Screening & Treatment - NHS Free*
Medicines Use Review - NHS Free*
New Medicines Service - NHS Free*
NHS Health Checks - NHS Free*
Minor Ailments Service - NHS Free*
*Exemption Details Required
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