Do you have any non-routine medical appointments upcoming, including scans, blood tests or investigations?
Have you had a Mary How Trust health screening before?
How did you hear about us?
Word of mouthI'm a previous clientCharity ShopSocial mediaOnline search engine - WebsiteLeafletEvent / Talk / NetworkingOther
First Name [please ensure this is your full name, not a nickname]
Date of Birth
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
Are you available for short-notice appointments?
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. 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 are committed to providing you the best experience possible. Do you have any additional needs or requirements for your visit? (e.g I'm hard of hearing). Please do not hesitate to let us know if you think that you may wish to have a chaperone to accompany you; we will ensure that an appropriately trained person is available.
You can also use this box for any other notes you would like to add.
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]
You can make a difference to someone’s life
The Colonnades, 17 London Road,
Pulborough RH20 1AS
Registered Charity 1122393