Request a Medical with the GP

Request a Medical

Please complete this form to request an appointment for a Medical with the GP.

Please supply as much information in the form as possible.

We will then contact you to arrange the appointment and advise you of the appropriate fee.

Title

First Name(s)

Surname

Date of Birth

Address

Contact Number

What type of medical do you require?

Anything else you would like to add or make us aware of?

I understand this is not covered under the NHS and will incur a charge

Yes

I consent to my information being used for the purpose described above and wish to submit this online form to Nelson Surgery, Bryncelyn, Nelson, Treharris, CF46 6HL

Yes