NHS Health Check Appointment Request

If you have been advised by the surgery to submit an NHS health check questionnaire, please use this form.

Please complete what you can. The clinician may go over some of the following question areas again during your health check appointment. Any answers from the questions below that you can complete will help them. If you are unsure of any sections or have answers that do not have an option, don’t worry as the clinician will be able to go over these during your appointment.

Your Details

NHS Health Checks are free for anyone aged between 40 and 74 years of age and does not already have a pre-existing condition. Patients can have a check once every 5 years.

It can tell you whether you're at higher risk of getting certain health problems, such as heart disease, diabetes, kidney disease, stroke and dementia.

Patient's Full Name *

Patient's Date of Birth (dd/mm/yyyy) *

Email Address *

Mobile Phone Number

Landline Phone Number

Named GP (if known)

Appointment Details

Appointment With *

Appointment Date *

Appointment Time *

Are you completing this form in response to our contacting you offering a free NHS Health Check? *

Yes

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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Page last reviewed: 08 April 2022
Page created: 14 October 2026

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NHS Health Check Appointment Request

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