NHS Health Check Appointment Request

Community Health Checks available at:

Bury St Edmunds

Felixstowe

Ipswich

Needham Market

Wickham Market

Appointments available on evenings and weekends

Pharmacy Health Checks available at:

Barbour, Ipswich

Hawthorn Drive, Ipswich

Woodbridge Road, Ipswich

Day Lewis, Bury St Edmunds

Lords, Newmarket

Needham Market

The Vyne, Elmswell

Personal Information

Please complete the following information about yourself

First Name*

Last Name*

Date of birth. Please tell us what day, month and year you were born*

Home Address*

Email address:*

Phone number*

What is the name of your doctor’s surgery:*

Have you had a health check in the last 5 years?*YesNo

Do you already have a health condition?*YesNo

If you ticked yes, please tell us more here:

Questions about your health check appointment

Please tell us where you would be happy to be seen; (you can tick more than one box) Your doctor’s surgeryA participating pharmacyA community clinic

Please tell us the best time for you to come for a health check; (you can tick more than one box) Monday – Friday, 9am – 5pmEvenings, 6.30pm – 8.30pmWeekends

Support for the health check
We want to make sure our services are fair and easy for everyone to use.

If you need any support to come to the health check, please tell us what support you need:

Do you need an interpreter at the health check? This is someone who speaks English and your language.*

Are you happy to be contacted via email or text message?

Thank you for answering our questions.