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01403 333756 EMERGENCIES

18 Carfax Horsham

West Sussex, RH12 1EB

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Confidential Medical History Form

To help us treat you safely it is required by law that all patients answer the following questions about their general health every 6 months regardless of whether or not anything has changed.

Please answer all questions with a `yes` or `no` and if necessary add any additional details. All information provided will be kept strictly confidential.
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Are you currently:

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Do you suffer from:

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Did you as a child or ever since have:

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(1 unit= ½ pint of lager; Single measure of spirits; Single glass of wine)

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Communication consent form

We process personal data for the purposes of providing optimum healthcare, sending important updates to you, providing you with news about treatments and informing you about our services. You can withdraw your consents at any time by email to or by calling .

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Your personal information held at Medical History Form will never be passed to third parties unless we are making a professional referral for you. If we have your consent for a referral to another health care provider we will send them just the information that they need to provide the necessary assessment, tests or treatments.

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What our patients say

“Absolutely brilliant service and great treatment! Lots of information to help choose the best treatment then very skillful work. Caring and kind too, and all on the NHS. A lucky find having moved to the area.”

N.M – Lewes

Google Reviews
96% Of our patients would recommend us