Health Screening Referral Form

Please fill out the form.

Patient Name:*
First Name
Last Name
Patient Address:*
Gender*
Date of Birth:*
DD
/
MM
/
YYYY
Phone Number:*
Mobile Number:
Your Email Address:*
Insurance Details:
Previous Attendance at Bon Secours Health Screening Department?*
Please state which Health Screening Package you require:
Comprehensive Health Screening for Men/Women - 420 Euro
Corporate Health Screening Package - 395 Euro
If Corporate Patient, please give Contact Name and Address of Company
Company Phone Number
GP Details
- GP Name:
  First Name
  Last Name
- GP Practice Address:
- GP Phone Number:
- Optional Extra Tests (Men/Women) Required:
  Cardiac Stress Test - 150 Euros
  Full Pulmonary Function Test - 60 Euros
  Dexa Scan (For Men/Women over 40) - 85 Euros
  Nutrition Screen & Consultation - 60 Euros
  Physiotherapy Consultation (If Required) - 50 Euros
- Extra Tests Required for Women only:
  Mammogram (For Women over 40) - 125 Euros
  Smear Test - 25 Euros
- Will accept Email Notification

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