Welcome to Breakspear Medical
Thank you for choosing us for your healthcare needs. We’re pleased to welcome you to our clinic and look forward to supporting you on your healthcare journey.
Secure & confidential
Your privacy is our priority. This medical questionnaire is protected by our HIPPAtizer programme, ensuring all your personal and medical information is securely encrypted and HIPAA-compliant. You can complete this form with complete confidence that your data is safe.
Before you begin
Please complete this questionnaire if you have not already provided us with a list of your Supplements & Medications.
This questionnaire is estimated to take a few minutes to complete. Please provide as much of the requested information as possible.
If you have any questions while completing this form, or if you need to discuss your appointment, please don’t hesitate to contact us.
We look forward to meeting you soon.
Supplement & medication list
Thank you for submitting your information. Your information will be securely received, and our Clinical Care Team will review your case and email or call you by your preferred method within 2 working days.
Privacy & data protection
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 information and healthcare services and/or contact you about your care.
- We never sell or share your personal information with third parties.
Security notice: while we use secure systems to protect your data, please note that submitting information online always carries some inherent risks.
If you need to update information or have further questions, contact us by telephone: +44 (0)1442 261 333 during opening hours.
