Application Form

Please complete the form below to request our concierge healthcare services.

Name

First Name

Last Name

Email

Mobile Number

Country

(###)

###

####

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Medical Issue?

Please indicate your current health concerns

Select Service

Preferred Start Date of Treatment

MM

DD

YYYY

Data Protection Notice

Confidentiality: The confidentiality of patient information is of paramount concern to IMH Services. To this end, IMH Services fully complies with the Data Protection Legislation and Medical Confidentiality Guidelines. Medical Information: Medical information will be kept confidential. It will only be disclosed to those involved with treatment or care. Requirement to share your data with Public Health Authorities (PH England): For any notifiable disease; Covid PCR testing in the event of a positive result, or if Covid PCR testing is being used for the Government Test to Release scheme. GDPR data protection agreement: I explicitly consent to you creating and storing medical records concerning my treatment, which may include details concerning my medication, treatment, and other issues affecting my health conditions, in accordance with the General Data Protection Regulation (GDPR). I understand that these records will be retained for eight years (or until I reach 25 in the case of someone aged 16 - 18), when treatment is ceased in order to comply with the General Medical Council guidelines. I understand that these records will be processed in accordance with your 2018 Privacy Notice, a copy of which I have seen.

Data & Privacy

I agree to the terms and conditions outlined in the Data Protection Notice.

I consent to the secure sharing of my medical information with healthcare professionals directly involved in my treatment and care.

I acknowledge and consent to my data being shared with Public Health Authorities for Covid-related testing or reporting purposes, as required by law.

I have read and agree to the IMH Services Privacy Policy and Terms & Conditions.

Marketing & Communcations

I consent to receiving updates, offers, and news from IMH Services. I can opt out at any time.

I consent to receiving communication from IMH Services about relevant updates, services, and offers. I understand I can opt out at any time.

Application Form

Integrated Mega Health Services Ltd

London, UK

Lagos, Nigeria