Registration · new patient

MEDii Registration Form

Please check and complete the details below so our clinical team is ready for your visit. It only takes a few minutes.

Clinical vitals and the General Assessment are recorded separately by the clinical team on the appointment page — they are not part of this patient form.

1. MEDii Registration Form / 脉德用户注册表

Prefilled from your patient record — edit anything that isn't right.

MRN / 病历号

Assigned by MEDii / 由脉德分配

First Name / 名*Last Name / 姓*

Preferred Name / 偏好名字

Date of Birth (DD/MM/YYYY) / 生日*Gender at Birth / 出生性别*

Contact Number / 联系电话*

Full Address / 地址*Email address for results / 电子邮箱*

Emergency Contact Name / 紧急联系人*Emergency Contact Mobile Number / 紧急联系人电话*

Your reason for today's attendance at MEDii / 今天前来脉德的原因Are you allergic to anything? / 您对任何物质过敏吗？Significant medical conditions to be aware of? / 任何需要注意的病史Please list any medications you are taking at present / 目前正在服用的药品Do you have any mood-related issues that you would like help with? / 您是否有任何与情绪有关的问题需要帮助

Note / 备注

2. Special-testing questions / 特殊检测问题

Optional — complete only the questions relevant to today's tests.

ALL BLOOD SUGAR RELATED TESTING / 用于血糖相关检测

The time you last had anything to eat / 最后一次吃东西的时间

GYNAECOLOGICAL RELATED TESTING / 用于妇科相关检测

Date of the first day of your last menstrual period (DD/MM/YYYY) / 末次月经第一天的日期Might you be pregnant at present? / 您现在有可能怀孕了吗

ALL ULTRASOUND RELATED TESTING / 用于所有超声波相关检测

Time of your last ultrasound, scanned areas and findings / 您上次接受超声波检查的时间，部位，及任何发现If having a pelvic ultrasound today, would you be happy to have a transvaginal (internal) ultrasound? / 如果您今天要做盆腔超声波检查，您是否愿意做经阴道（内部）超声波检查？

Would you like a chaperone to be present at the time of your ultrasound? / 您是否希望在超声波检查时有陪同在场

3. Patient Consent / 病患授权

Please read each statement, then confirm your agreement below.

1. I acknowledge that my referring doctor/MEDii Health have explained the proposed procedure.
2. I have been provided with information regarding the proposed procedure.
3. I understand the risks and complications involved in the procedure.
4. I understand I have the right to change my mind at any time including after I have signed this form but, preferably following discussion with my doctor.
5. I have been provided the opportunity to have any questions answered.
6. I therefore give my consent for the above examination to be performed.

I agree / 本人同意*Patient Name / 病患姓名*

Patient signature / 本人签名*

Signature required before you can submit.

Date / 日期*

4. Consent to Disclose Personal Healthcare Information / 个人医疗信息代理授权书

Please read the authorisation below, then confirm your acceptance.

In order to provide our services, MEDii seeks your consent to share your medical information and other personal data related to your care. This is to enable MEDii Health to liaise about your health with our partners and other subsidiaries within the UK and abroad. This consent also gives your permission to receive and relay such information on your behalf to or from the relevant organisations or professionals involved in your care. MEDii will also share the information to emergency services, your emergency contact and your GP as necessary for your safety, when required. I hereby provide my consent and I fully authorise MEDii Health to contact any relevant persons and relevant organisations on my behalf; MEDii Health can share all relevant personal and medical information regarding my health and treatments to its health partners, subsidiaries and other medical providers or organisations for the purpose of facilitating my health, treatment, and management of care. The said information can be in person, by telephone, other electronic means or via remote consultations. I understand that I can refuse to provide my consent and my refusal to sign or the withdrawal of my consent could affect the ability of MEDii Health and other relevant health care organisations to provide the services that I require. This is also to confirm that I have full understanding of the matters discussed including the MEDii Privacy Policy document.

I have read and accept this authorisation / 本人已阅读并同意本授权*

Client / Patient · 客户 / 病患

Signature / 签名

Date / 日期Printed Name / 姓名Contact / 联系方式Email / 电子邮箱

5. Appointment Terms & Conditions (V2.1) / 预约条款与条件 (V2.1)

Please read the Appointment Terms & Conditions (V2.1) and accept below.

Appointment Terms & Conditions — Late arrival, cancellation, rescheduling and missed appointments · Version 2.1 · Effective 10 July 2026 · 18 Duke's Road, London WC1H 9PY

At a glance

Situation

What happens

Arrive ≤15 min late

Seen for the remaining time at the standard fee.

Arrive >15 min late

Full-length where the diary allows (extension fee agreed at check-in); otherwise the remaining time if clinically safe, else treated as missed.

Cancel / reschedule >48h before

Full refund / free rebooking — no charge.

Cancel / reschedule 24–48h before

50% retained (refunded if the slot is refilled).

Cancel / reschedule <24h before

Not possible — 100% of the fee applies.

Miss without notice

100% of the fee is charged.

Extra / amended documents >7 days after

Quoted admin fee, agreed in advance (our errors corrected free).

MEDii cancels / significantly delays

Priority rebooking or full refund — no charge to you.

Read the full Terms & Conditions (PDF)

Open the full Terms & Conditions (PDF)I have read and accept the Appointment Terms & Conditions (V2.1).*

Complete the required fields, both consents, the Terms acceptance and your signature to submit.