For Patients

Before we finalise your eligibility...
Permission to store*
- I give MyAccess Clinics permission to store and use the information I share in this form to communicate with me, and to care for my wellbeing.
Terms and conditions*
- I agree to the My Access Clinics terms and conditions and the privacy policy.
You can withdraw your permission at any time by contacting ukprivacy@myaccessclinics.com

Any information you share with us in this form will never be shared with a third party.

Step 1

Step 2
Based on the information you have provided us so far, you are eligible for an assessment. Let’s continue with some contact details.
Contact Details*
- I'm a patient
- I'm a carer or guardian of the patient
Carer or Guardian Details
In all other cases, we’ll need to speak directly to the patient. If they have any difficulty communicating, please give us guidance on the best time to call them if you’d like to be present to assist them.
Legal guardianship
- I hold legal guardianship and have consent of the patient. If so, we will contact you directly.
Carer/ Guardian Name*
First Last
Carer/ Guardian Email*
Carer/ Guardian Phone*
Please enter a valid UK phone number. It should start with 0 or +44, and be at least 11 digits long.
Patient Details
Name*
First Last
Email*
Phone Number*
Please enter a valid UK phone number. It should start with 0 or +44, and be at least 11 digits long.
Address*
Street Address Address Line 2 City Postcode
Best time to call and arrange a consult*

Before we finalise your eligibility...