New Patient Referral – VW

New Patient Appointment (VW)

Please do not use this form if you have not secured an appointment or discussed all elements of the process including all costs with the patient. Please email a basic ‘Interested Party Referral’ to us if that is all you are wishing to provide.

All consultations are currently being undertaken remotely using clinic software and it is important that all patients check the link/connection is working ahead of their consultation appointment so that any issues can be resolved. Full details are provided in the appointment confirmation email and there is no risk of connecting with a doctor or other patient!

A small red '*' symbol denotes a required field.
Please enable JavaScript in your browser to complete this form.
Patient Title
Patient Name
Does patient have any pre-existing conditions, illnesses, allergies or disabilities?
Complete the section below if you answered Yes.
Hormone Treatment
An appointment will be allocated automatically at a time/day specified above but can be rearrange by the patient if not convenient. A confirmation plus details will be emailed to the patient, along with an invoice from our merchant 'Stripe' which should be paid in order to secure the appointment.
Have you outlined the process and costs to the patient? Please tick all that you have discussed and explain that consultations are conducted remotely, with details in their confirmation email.
The initial phase of treatment (from first consultation to 3-month review) is the most costly phase. The doctor will determine each review period and ongoing diagnostic requirements based on a patient's individual treatment needs.
What do you believe is the patient's intention?
Patient's Marketing Preference
We DO NOT pass details on to anyone else.
Read our February 2020 article in the Daily Mail
Read our February 2020 article in the Birmingham Post