About You

Title

First Name [please ensure this is your full name, not a nickname]

Middle Name(s)

Last Name

Address 1

Address 2

Town

Postcode

Date of Birth

Sex

Contact Details

Email Address

Would you like to receive occasional email updates from the Mary How Trust? (e.g newsletters)
Yes PleaseNo thank you

Mobile Phone Number

Home Phone Number

Preferred Phone?
HomeMobile

Your Availability

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

Your Donation

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. Your health screening will cost us £350 and if you can cover this cost or make a donation towards this, you will help to ensure we can continue to provide our important health screening service. Thank you!

When/how would you like to make a donation?

In the clinic at my appointmentPrior to my appointments by bank transfer or through the websiteAfter my appointments by bank transfer or through the websiteSet up a standing orderI already donate monthlyMy employer/corporate - please let us know details at the bottom of the pageI've been given a screening gift voucherN/A

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]