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ONLINE DOCTOR CONSULTATION REQUEST FORM

Type of Consultation

Please select

Personal details

Date of Birth
Day
Month
Year
Preferred method of contact
Email
Phone

You will be contacted by the doctor shortly after submitting your request

Request overview

Briefly describe your symptoms, when they started etc

Current Medication

Are you currently taking any medication?
Yes (please provide brief details)
No

Medical background

Give as much details as possible including dates

Are you currently under the care of a GP or specialist in the UK?
Yes
No

Upload supporting documents

(Multiple uploads allowed)

  • GP summaries (or screenshots of NHS App GP records)

  • Clinic letters

  • Blood test results

  • Imaging reports (MRI/CT/Ultrasound)

  • Discharge summaries

  • Medication lists (or pictures of meds)

  • Photos of paper documents

  • Photos of any abnormal changes or concerns eg. rash, swelling, lump etc


Date
Day
Month
Year
Online Doctor Consultation

Clarity Medicine

Dr Ali Khalil MBChB
GMC Registered Doctor

GMC No: 6137333

 

Independent Private Services
Cambridge, United Kingdom

info@claritymedicine.co.uk

Mobile / WhatsApp: +447802782563

 

Privacy Policy | Terms & Conditions | Disclaimer

Clarity Medicine provides independent private medical assessments and documentation. Services do not replace NHS GP care.

 

Clarity Medicine is a trading name of Pharmedical Ltd, registered in England and Wales.
Company number: 14719215
VAT number: GB 4864055567

© 2026 Clarity Medicine

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