Appointment Request Form - The Medic Clinic Bedford

Request an Appointment!

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Contact Details

Title*

Your Name*

First Name Middle Name Last Name

Contact No*

Email*

Enter Email Confirm Email

Address*

Door No Street Name City/Town County Postal Code

Date of Birth*

Service Required

Please choose the treatment that you wish to make a booking for. If the service you require is not listed, please call us on 01234 984065

Treatment of interest*Please choose the treatment that you wish to make a booking for. If the service you require is not listed, please call us on 01234 984065

Please Note*

For ‘Pregnancy’ and ‘Other’ scans, we only have Sunday’s available; For ‘Musculoskeletal’ scans, we only have Thursday’s available. We apologise for any inconvenience this may cause.

Please check the box above if you wish to continue

Please Note*

We only have Saturday’s available for our Gynaecology clinics. We apologise for any inconvenience this may cause.

Please check the box above if you wish to continue

Please Note*

We only have Tuesday’s available for our skin lesion removal clinics. We apologise for any inconvenience this may cause.

Please check the box above if you wish to continue

Please Note*

We only have Friday’s available for our Physiotherapy clinics. We apologise for any inconvenience this may cause.

Please check the box above if you wish to continue

GP Services

If the service you require is not listed below, please call us on 01234 984065

Please select a service*

General GP appointment (£55.00)

Basic health MOT (£90.00)

Comprehensive health MOT (230.00)

Medical assessments for work/travel (£75.00+)

Ear microsuction for ear wax removal (one ear) (£55.00)

Ear microsuction for ear wax removal (two ears) (£80.00)

Private prescription only (£30.00)

Specialist referral letter (£55.00)

ECG (£50.00)

Minor injury suture (£65.00)

MRI scan (£400.00+)

CT scan (£400.00+)

Hayfever injection (£80.00)

Corticosteroid injection (£150.00)

Intralesional steroid injection (£150.00)

Cervical smear test (£150.00)

Spanish visa medical certificate (£75.00)

Have you had this injection previously?*

Please specify when did you have a Hayfever injection*

Area of concern:*

Reason for appointment:*

Have you had this injection previously?*

Please specify when:*

Please specify exactly why you require this medical assessment:*

Please specify which department you would like to be referred to:*

Please specify why you require this referral:*

Please specify area of injury:*

Which area of the body requires a scan?*

Reason for scan:*

Any further details?

GP Services - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Blood Tests

Consent*

I acknowledge that this is a private service and not an NHS free service.

Blood test wanted*

General Health Screen (£70.00)

Well Man Health Screen - Basic (£160.00)

Well Woman Health Screen - Basic (£160.00)

Well Man Health Screen - Comprehensive (£180.00)

Well Woman Health Screen - Comprehensive (£180.00)

Allergy Testing - Comprehensive (£300.00)

Female Hormone Profile (£150.00)

PCOS - Polycystic Ovary Syndrome Check (£160.00)

Male Hormone Profile (£150.00)

Sexual Health Testing - Basic (£110.00)

Sexual Health Testing - Comprehensive (£320.00)

Pregnancy Blood Test (£55.00)

Full Blood Count (£35.00)

Thyroid Screen (£90.00)

Vitamin D (£60.00)

Progesterone - Day 21 (£45.00)

CA 125 (£60.00)

Testosterone (£45.00)

Other (not listed)

We provide an extensive range of blood tests that aren’t all on our website, so if you have a more specific request please let us know below:

Reason for appointment:*

Any further details?

Blood Tests - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Ultrasound Service

What type of scan do you need?*

Pregnancy scan

How many weeks pregnant are you currently?*

Please choose the services that you are interested in:*

Early pregnancy scan (6 weeks+)

Reassurance scan (6 weeks+)

Nuchal Translucency scan (11-14 weeks)

Gender scan (16 weeks+)

Anomaly scan (18-21 weeks)

Growth scan (23-40 weeks)

3D/4D scan – includes 2 photos (24-32 weeks)

Reason for appointment:*

Any further details?

Pregnancy scan - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Please note: Due to limited availability, we are currently only able to offer Sundays for our scan clinics. We apologise for any inconvenience this may cause.

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Deposit and Refund*

I understand that a deposit of £25.00 will be required to secure this appointment. This amount will be refunded if cancelled a minimum of 48 hours prior to the appointment.

Musculoskeletal scan

Please specify exactly what area you require a musculoskeletal ultrasound scan for:*

Ankle/Foot

Elbow/Forearm

Hip/Upper Thigh

Knee

Shoulder/Upper Arm

Wrist/Hand

Other

Please specify what scan you require:*

Reason for appointment:*

Any further details?

Musculoskeletal scan - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Please note: Due to limited availability, we are currently only able to offer Thursdays for any Musculoskeletal scans. We apologise for any inconvenience this may cause.

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Deposit and Refund*

I understand that a deposit of £25.00 will be required to secure this appointment. This amount will be refunded if cancelled a minimum of 48 hours prior to the appointment.

Gynaecology and Fertility

Please choose the areas of interest for you scan:*

Upper abdomen – liver/pancreas/spleen/gall bladder

Lower abdomen – kidneys/bladder/renal tract

Internal pelvic – looks at the female reproductive organs

Follicle tracking - looks at the number and size of ovarian follicles

3D internal pelvic

Abdominal aorta - checks for aneurysms

DVT - assesses your veins for any clots

Lower leg venous - checks for any venous insufficiencies

Carotid doppler - checks your carotid arteries for any blockages

Arterial doppler - checks your large arteries and veins for any blockages

Lumps and bumps

Hernia

Thyroid/neck

Scrotum/penile

Prostate

Not sure

Please specify below exactly what type of ultrasound you require:

Reason for appointment*

Any further details?

Other ultrasound scans - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Please note: Due to limited availability, we are currently only able to offer Sundays for our scan clinics. We apologise for any inconvenience this may cause.

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Gynaecology and Fertility

What service do you require?*

Consultation

Internal pelvic scan

Follicle tracking Scan

Pregnancy reassurance scan

Cervical screening/smear

Contraception removal

Contraception implant insertion

Copper coil insertion

Hormone coil insertion

HyCosy tube testing

Incision & drainage

Ring pessaries change

Prolapse assessment and pessary insertion

Repair or refashioning of vulval or perineal scar

Cervical polypectomy

Endometrial biopsy

Other

How many weeks pregnant are you?*

Have you had a vaginal delivery previously?*

Consent*

I understand that if I am under 25, I may be asked to book in a Chlamydia/Gonorrhoea swab a minimum 4 days before my appointment, with the charge being an additional £60.00

Please specify:*

Reason for appointment:*

Any further details?

Gynaecology and Fertility - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Please note: We are only able to offer Saturdays for our Gynaecology clinics. We apologise for any inconvenience this may cause.

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Consent*

I understand that a deposit of £50.00 will be required to secure this appointment. This amount will be refunded if cancelled a minimum of 48 hours prior to the appointment.

Skin Surgery and Dermatology

What service would you like to book with us?**

Skin lesion removal

Skin lesion assessment (e.g. Dermoscopy)

Skin condition consultation

Skin lesion removal

How many lesions require removal?*

Are you willing to pay an additional £160.00 if a histology is recommended - to determine that the lesion is benign?*

Have you had any previous consultations / diagnoses regarding these lesions?*

Please specify:*

Where are these skin lesions located?*

Do you have pictures that show the areas of concern ?*We require these images to forward onto our specialist Doctors. This allows them to quickly confirm if they can treat this specific skin concern before booking you in for an appointment.

Attach your images*

Drop files here or

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 700 MB, Max. files: 8.

Any further details?

Skin lesion removal - Date and Time

Please note: We only have Tuesday's available for skin lesion removals. We apologise for any inconvenience this may cause.

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Consent*

I understand that a deposit of £50.00 may be required to secure this appointment. This amount will be refunded if cancelled a minimum of 48 hours prior to the appointment.

Skin lesion assessment

How many lesions require assessment?*

Have you had any previous consultations / diagnoses regarding these lesions?**

Please specify:*

Where are these skin lesions located?*

Do you have pictures to show the areas of concern ?*We require these images to forward onto our specialist Doctors. This allows them to quickly confirm if they can treat this specific skin concern before booking you in for an appointment.

Attach your images*

Drop files here or

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 700 MB, Max. files: 8.

Any further details?

Skin lesion assessment - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Consent*

I understand that a deposit of £50.00 may be required to secure this appointment. This amount will be refunded if cancelled a minimum of 48 hours prior to the appointment.

Skin condition consultation

Have you had any previous consultations / diagnoses regarding the areas of concern?*

Please specify*

Where are the affected areas located?*

Do you have pictures to show the areas of concern?*We require these images to forward onto our specialist Doctors. This allows them to quickly confirm if they can treat this specific skin concern before booking you in for an appointment.

Attach your images*

Drop files here or

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 700 MB, Max. files: 8.

Any further details?

Skin condition consultation - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Consent*

I understand that a deposit of £50.00 may be required to secure this appointment. This amount will be refunded if cancelled a minimum of 48 hours prior to the appointment.

Vitamin Infusions & Shots

Which infusion or shot would you like to be booked in for?*

If unsure, please click here to open the link in a new window.

Vitamin C and Glutathione 25g Infusion

Vitamin C and Glutathione 50g Infusion

Wellness Myers Infusion

Wellness Myers (B-Complex Modified) Infusion

Saline Drip

B12 Booster Shot

B-Complex Booster Shot

Vitamin D Injection

Other

Please specify*

Have you had this treatment before?*

Did you have this treatment previously at our clinic?*

Reason for appointment:*

Any further details?

Vitamin Infusions & Shots - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Mental Health

Reason for appointment:*

If there is any additional information you want us to know, please specify:

Mental Health - Date and Time

We provide a free 20-minute phone consultation beforehand to ensure you get the most out of your initial therapy session.

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of phone consultation*

DD slash MM slash YYYY

Preferred time of phone consultation*

Physiotherapy

Area of the body you would like to focus on:*

Reason for appointment:*

Have you been treated by our Physiotherapist at our clinic previously?*

Were you treated for the same issue as mentioned above?*

Any further details?

Physiotherapy - Date and Time

Please note: Due to limited availability, we are currently only able to offer Fridays for our Physiotherapy clinics. We apologise for any inconvenience this may cause.

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Consent*

I understand that a deposit of £25.00 will be required to secure this appointment. This amount will be refunded if cancelled a minimum of 48 hours prior to the appointment.

Cardiology

What service do you require?*

Consultation

24-hour BP check

24-hour ECG

Exercise ECG

Transthoracic echocardiogram

Bubble contrast echocardiogram

Stress echocardiogram

Contrast echocardiogram

Insurance medical

Cabin crew medical

Pilot medical

Other

Please specify:*

Reason for appointment:*

Any further details?

Cardiology

Please note: We run our cardiology service on an external referral basis where Lynne, Dr Timperley’s secretary, will be in contact to discuss this booking in further detail with you

Would you like to book an initial consultation with one of our GP’s (for £55.00) prior to arranging a referral to our Cardiologist?*

Date and time for the appointment

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of GP appointment*

DD slash MM slash YYYY

Preferred time of GP appointment*

Dermal Fillers and Anti-Wrinkle Injections

What treatment are you interested in?*

General aesthetics consultation

Anti-wrinkle injections – 1 area

Anti-wrinkle injections – 2 areas

Anti-wrinkle injections – 3 areas

Hyperhidrosis (excessive sweating – underarms)

Teeth grinding

Gummy smiles

Bunny lines

Lips

Jawline correction

Cheeks

Tear troughs

Non-surgical rhinoplasty (nose job)

Nasolabial folds (nose to mouth lines)

Marionette lines (mouth to chin lines)

6-point face lift

Other

Please specify:*

Reason for appointment:*

Any further details?

Dermal Fillers and Anti-Wrinkle Injections - Time and Date

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Consent*

I understand that a deposit of £25.00 will be required to secure this appointment. This amount will be refunded if cancelled a minimum of 48 hours prior to the appointment

HydraFacial

What treatment are you interested in?*

Which hydrafacial are you interested in? If unsure, please click here to open the link in a new window.

Have you had this treatment before?*

Please specify when:*

Reason for appointment:*

Any further details?

HydraFacial - Checklist

Do you have any allergies (specifically to shellfish or aspirin)?*

Please specify:*

Do you suffer from any autoimmune diseases (including HIV, Lupus, Hepatitis and Scleroderma)?*

Please specify:*

Are you currently pregnant?*

Oh no! Unfortunately, our HydraFacial treatment isn’t suitable for those who are currently pregnant therefore you will not be eligible for this service.

Are you currently breastfeeding?*

Oh no! Unfortunately, our HydraFacial treatment isn’t suitable for those who are currently breast feeding therefore you will not be eligible for this service.

Do you currently have any active infections on your face e.g., cold sores?*

Oh no! Unfortunately, our HydraFacial treatment isn’t suitable for those who are currently experiencing any form of facial infection therefore you will not be eligible for this service.

Have you had any Anti-wrinkle injections or Facial waxing in the last 7 days?*

Please specify the date of your last treatment:*

Have you had any Fillers in the last 10 days?*

Please specify the date of your last treatment:*

Have you had any Skin Peels in the last 30 days?*

Please specify the date of your last treatment:*

HydraFacial - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Consent*

I understand that a deposit of £25.00 will be required to secure this appointment. This amount will be refunded if cancelled a minimum of 48 hours prior to the appointment.

Microneedling

Have you had Microneedling treatment before?*

Please specify when:*

Reason for appointment:*

Microneedling - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Consent*

I understand that a deposit of £25.00 will be required to secure this appointment. This amount will be refunded if cancelled a minimum of 48 hours prior to the appointment.

Obagi Blue Peel

Have you had this treatment before?*

Please specify when:*

Reason for appointment:*

Obagi Blue Peel - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Consent*

I understand that a deposit of £25.00 will be required to secure this appointment. This amount will be refunded if cancelled a minimum of 48 hours prior to the appointment.

Skin Boosters

Consent*

I can confirm that I have none of the conditions listed below:

*Pregnant/Nursing
*HIV/AIDS
*Cancer (all forms)
*Undergoing chemotherapy or immunotherapy
*Immunodeficiency
*Lupus
*High blood pressure (uncontrolled)
*Insulin dependent diabetics
*Prednisone and other steroid medications (treatment will increase inflammation)
*Heart problems or diseases
*Haemorrhagic disease, trauma, or bleeding
*Scleroderma
*Family history of hypertrophic scarring or keloid formation
*Solar Keratosis
*Blood thinners (including but limited to warfarin or aspirin)
*Nickel or stainless-steel allergies
*Active acne
*Pregnant or breastfeeding
*Am under 18 years of age

What skin booster would you like to book?*

If unsure, please go to our Menu > choose ‘Services’ > choose ‘Skin Boosters'

Profhilo

Jalupro

Sunekos

Unsure

Have you had this treatment before?*

Please specify when:*

Reason for appointment:*

Skin Boosters - Checklist

Are you currently taking any medication?*

Please give details*

Are you currently receiving any medical treatment?*

Please give details*

Have you had any injuries or operations (including dental work) in the last two years?*

Please give details*

Have you previously received any aesthetic treatments (e.g., laser, peels, dermabrasion, dermal fillers, botulinum toxin, fat dissolvers etc.)?*

Please give details*

Any history of allergies/anaphylaxis?*

Please give details*

Do you have a known sensitivity to Lidocaine (numbing agent commonly used by dentists or doctors)?*

Please give details*

Do you have a known hypersensitivity (allergy) to hyaluronic acid or any other injectable dermal aesthetic product?*

Please give details*

Is there any possibility of pregnancy or are you breastfeeding?*

Please give details*

Do you have any acute or chronic skin disease in / or near the area to which you require the treatment?*

Please give details*

Do you suffer from herpes simplex (cold sores)?*

Please give details*

Are you taking steroids, aspirin, warfarin, or blood thinners?*

Please give details*

Skin Boosters - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Consent*

I understand that a deposit of £25.00 will be required to secure this appointment. This amount will be refunded if cancelled a minimum of 48 hours prior to the appointment.

Fat Dissolving Injections

Which area requires treatment?*

Face (double chin or jawline)

Lower abdomen

Love handles

Inner or outer thighs

Upper arms

Other

Please specify:*

Have you had this treatment before?*

Please specify when:*

Fat Dissolving Injections - Checklist

Do you ever suffer from any auto-immune disease or disease affecting the immune system?*

Please give details*

Do you have any cutaneous (skin) infection or inflammatory problems (e.g., herpes, acne etc.)?*

Please give details*

Are you currently taking any steroids, aspirin or blood thinners (e.g., warfarin, apixaban, rivaroxaban etc.)?*

Please give details*

Do you suffer from severe kidney disease?*

Please give details*

Have you previously received any aesthetic treatments (e.g., laser, peels, dermabrasion, dermal fillers, botulinum toxin, fat dissolvers etc.)?*

Please give details*

Are you receiving any medical treatments?*

Please give details*

Have you previously had a hypersensitivity reaction?*

Please give details*

Any history of severe allergy/anaphylaxis?*

Please give details*

Fat Dissolving Injections - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Consent*

I understand that a deposit of £25.00 will be required to secure this appointment. This amount will be refunded if cancelled a minimum of 48 hours prior to the appointment.

PRP Therapy

What type of PRP would you like to book?*

Hair PRP

Face PRP

Have you had PRP treatment before?*

Please specify when:*

Reason for appointment:*

Any further details?

PRP Therapy - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Consent

I understand that a deposit of £25.00 will be required to secure this appointment. This amount will be refunded if cancelled a minimum of 48 hours prior to the appointment.

Ingrown Toenail Removal

Is it your big toenail that’s affected?*

How long have you had this ingrown toenail?*

Is the area currently infected?*

Are you on any antibiotics to treat this infection?*

Have you used any other treatment so far?*

Please specify:*

Any further details?

Ingrown Toenail Removal - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Corn Removal

What area of the foot is the corn located on?*

How long have you had this corn?*

Have you used any treatment so far?*

Please specify:*

Any further details?

Corn Removal - Date and Time

This will allow us to try and accommodate a date and time that best suits you, but does not act as a guarantee

Preferred date of appointment*

DD slash MM slash YYYY

Preferred time of appointment*

Why Choose Us

CQC registered clinic

We are a registered clinic with the Care Quality Commission.

Friendly team

We work with some of the most experienced consultants and healthcare specialists from across the United Kingdom

Great range of services

We have numerous services available from Doctor led consultations to physiotherapy and vitamin infusions.

Accessible appointments

We offer appointments daily for all our services.

Affordable pricing

Highest quality services and treatments at affordable prices.

Great location

We are based on the High Street in Bedford Central. Our location is easily accessible and convenient for our clients.

Request an Appointment!

Contact Details

Service Required

GP Services

GP Services - Date and Time

Blood Tests

Blood Tests - Date and Time

Ultrasound Service

Pregnancy scan

Pregnancy scan - Date and Time

Musculoskeletal scan

Musculoskeletal scan - Date and Time

Gynaecology and Fertility

Other ultrasound scans - Date and Time

Gynaecology and Fertility

Gynaecology and Fertility - Date and Time

Skin Surgery and Dermatology

Skin lesion removal

Skin lesion removal - Date and Time

Skin lesion assessment

Skin lesion assessment - Date and Time

Skin condition consultation

Skin condition consultation - Date and Time

Vitamin Infusions & Shots

Vitamin Infusions & Shots - Date and Time

Mental Health

Mental Health - Date and Time

Physiotherapy

Physiotherapy - Date and Time

Cardiology

Cardiology

Date and time for the appointment

Dermal Fillers and Anti-Wrinkle Injections

Dermal Fillers and Anti-Wrinkle Injections - Time and Date

HydraFacial

HydraFacial - Checklist

HydraFacial - Date and Time

Microneedling

Microneedling - Date and Time

Obagi Blue Peel

Obagi Blue Peel - Date and Time

Skin Boosters

Skin Boosters - Checklist

Skin Boosters - Date and Time

Fat Dissolving Injections

Fat Dissolving Injections - Checklist

Fat Dissolving Injections - Date and Time

PRP Therapy

PRP Therapy - Date and Time

Ingrown Toenail Removal

Ingrown Toenail Removal - Date and Time

Corn Removal

Corn Removal - Date and Time

Why Choose Us

CQC registered clinic

Friendly team

Great range of services

Accessible appointments

Affordable pricing

Great location

The Medic Clinic Bedford

Contact Us