Confidential Medical History
A detailed history helps us prepare for your consultation. This form is built so it never asks for your name, email, phone number, or any other directly identifying detail — only your health information.
How this stays private
This page generates a random reference code for you below. Save it, then simply mention that code at the start of your consultation (or include it in your appointment request notes). Your health history is never stored alongside your name — the two are only connected when you provide the code yourself. Please don't type your name or contact details into any of the text boxes below.
Write this down or copy it now — you'll need to bring it to your consultation. It is not saved anywhere else and won't be shown again after you leave this page.
History received
Thank you. Please keep your reference code and mention it at the start of your consultation, or include it in the notes of your appointment request, so we can match this history to your visit.