About You

This information is necessary for us to process your appointment request.

Title

First Name

Last Name

Address 1

Address 2

Town

Postcode

Home Phone

Mobile Phone

Preferred Phone?
HomeMobile

Email Address

I would like to receive occasional email updates from the Mary How Trust e.g newsletters
Yes PleaseNo thank you

Date of Birth

Gender

How did you hear about us?

Are you available for short-notice appointments?
YesNo

Any further details on your availability e.g. preferred days of the week and any holiday dates

Instead of a fixed fee for our health screenings, we ask for a donation that’s based on ability to pay.
We encourage clients to give generously for their screenings, but never turn anyone away if they’re
unable to donate the full cost.

When/how would you like to make a donation?

In the clinic on the day of my appointmentsPrior to my appointments by bank transfer or through the websiteAfter my appointments by bank transfer or through the websiteSet up a standing orderMy employer/corporateN/A

Do you have any additional needs or requirements for your visit? (e.g I'm hard of hearing)

We’d like to talk this through with you before registering you for an appointment. Please do get in touch on 01798 877640 or [email protected]