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Patient Information

Gender at birth
Male
Female
Preferred Method of Contact
Email
WhatsApp
Text Message
Phone Call
Preferred Time of Contact
Morning
Afternoon
Evening

Please describe what you would like help with and your main questions

Please describe your current medical condition and provide as many details as you can

  • Current Diagnosis / Condition (if known)

  • When were you diagnosed?

  • Current symptoms (if any) and when they started

  • Relevant past medical history

  • Current medications (list or upload photo)

Preferred Date and time
Day
Month
Year
Time
HoursMinutes

We will contact you within 24 hours to confirm availability

Upload all the documents relevant to your request

(Multiple uploads allowed)

  • Clinic letters

  • Blood test results

  • Imaging reports (MRI/CT/Ultrasound)

  • Discharge summaries

  • Medication lists

  • Photos of paper documents

Upload up to 20 documents (PDF, JPG, PNG, DOCX)

Patient Consent Statement

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Date
Day
Month
Year
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