Patient Registeration Form

Please complete the form below to register for our online doctor and pharmacy services.

Your Legal Name
As it appears on your passport or ID

First Name

Last Name

Address

Address (UK Only)

Postal Code

Account Details

Email Address

Password

Confirm Password

Contact and Personal Info
Telephone Number
In some cases, our clinicians may need to call you. They will always be discreet.

Phone number

Additional phone number

Date of Birth
Some medications have age restrictions
Assigned sex at birth
This is so that we can prescribe you safe and approproate medications.
GP Practice

Address (Must be UK)

Postcode

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