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Patient Intake Form

Simply call +44 (0) 1442 261 333 to speak with a member of our Patient Liaison Team who will help you decide which professional to visit first.  (No referral needed.) They will provide you with all the information you need to arrange your consultation and answer any questions you may have.

Please note: while we run a childhood immunisation clinic, at this time, we are not treating new patients under the age of 18 in our main clinic.

Opening hours are 9:00am to 5:00pm, Monday to Friday (excluding bank holidays).

Scent-free clinic

We ask all patients and visitors not to wear anything perfumed/scented when attending the clinic. Anyone wearing scented products may be asked to wash or shower and change into a hospital gown during their visit to reduce the impact.  More information on becoming scent-free.

Online Patient Intake Form

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    Your information will be securely transmitted to our intake team, who will reach out to you with the information you've provided above.


    By submitting this form, you agree that:

    • Your information will be stored and processed in accordance with GDPR requirements.
    • We will only use your information to provide healthcare services and contact you about your care.
    • We never sell or share your personal information with third parties.
    • While we take reasonable steps to protect your information, please be aware that data submitted through standard internet forms carries inherent security risks.

    © 2024 Breakspear Medical Group Ltd. All rights reserved.
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