Registration Form

All information is held in the strickest confidence

98 Longbridge Road
Barking
Essex IG11 8SF
Your details
Emergency Contact
YOU MUST PROVIDE US WITH THE VALID EMAIL ADDRESS OTHERWISE WE CAN NOT PROVIDE A CONSULTATION
Safety check

Do you have any heart trouble, pacemaker or high blood pressure?

Do you have any chest problems e.g. tuberculosis or asthma?

Do you suffer from epilepsy, fainting or blackouts?

Are you diabetic?

Have you ever come in contact with anybody whi has AIDS or are suspecter AIDS?

Do you suffer from any allergies? (including alergy to local anaesthetic)

Are you pregnant? (if applicable)

Have you ever had any serious illness?

Have you had any operations?

Please note that online or phone consultation with a doctor is NOT to be used in an EMERGENCY situation IF YOU BELIEVE THAT YOU OR THE PERSON YOU ARE ASSISTING IS IN AN URGENT OR EMERGENCY SITUATION YOU SHOULD IMMEDIATELY DIAL 999. YOU SHOULD CALL 999 IMMEDIATELY in a critical or life-threatening situation, such as if someone has: difficulty breathing; severe bleeding and it can't be stopped; severe chest pain; a severe allergic reaction; severe burns or scalds; loss of consciousness; major trauma such as the result of a serious road traffic accident, a stabbing, a shooting, a fall from height or a serious head injury; or acute confused states and fits which aren't stopping, or if you believe someone is having a heart attack or stroke.

Medical Disclaimers: You should always seek the advice of a doctor or other qualified healthcare provider regarding any medical concerns (and before starting, stopping or modifying any treatment or medication) even if you have already obtained medical advice via online consultation with us. Dental and Medical Clinic in Barking does not guarantee that a video/chat/picture message consultation is the best course of accessing advice or indeed the appropriate course of treatment for your particular healthcare concern or medical issue. You agree to contact your GP or hospital immediately should your condition change or your symptoms worsen (if you are not registered with a UK doctor you agree to contact your local walk-in centre or hospital for advice). In an emergency, you should contact your nearest emergency services centre immediately.

I understand that this is a private medical consultation and I will be charged a consultation fee and that any further treatment or investigations may occur additional charges, as outlined in the current price list. If I am unsure about the total cost of my treatment or investigations, I will seek clarification from staff in advance. I am a self-pay patient, I will settle my bill in full prior to consultation. I understand that there is no obligation to proceed with treatment or investigation after the initial consultation and all prescriptions are non-returnable.
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