EliosCare Patient Portal

By submitting my application, I understand that Elios Clinics will receive my information and may reach out to me via phone, email, or SMS regarding my treatment. *

I consent to receiving email communication and updates from Elios Clinics on a regular basis. *

I consent for Elios Clinics to obtain my medical records and accept Terms and Conditions. This is required so we can safely review your treatment and support you with the right care. *

Read the Terms and Conditions before you submit this form.

Are you completing the form on behalf of someone else? *

YesNo

Title *

First name *

Last name *

Date of birth *

Gender *

Email address *

Phone number *

Street address *

Street address line 2

City *

Postcode *

Country *

Where did you hear about us? *

GP email address

GP telephone

Medical centre or GP surgery name

Street address

Street address line 2

City

Postcode

Country

Select option *

I will provide summary of my NHS records

I would like Elios Clinics to request my summary care records from my GP or Elios Partners

Your signature *

Date *

Assessment form