Functional Medicine Clinic Belfast | Northern Ireland Specialists

First Name

Last Name

Email Address

Telephone Number

Preferred contact method

Email Telephone Either email or telephone

What are the three main health concerns you would like help with?

How long have these concerns been present?

Less than three months Three to twelve months One to three years More than three years

Have you received any diagnoses relating to these concerns?

What investigations or treatments have you already had for these concerns?

What are you hoping to achieve by working with Beechill Clinic?

Are you open to making changes to areas such as nutrition, physical activity, sleep and recovery where appropriate?

Yes Yes, but I may need support I am unsure I am not currently looking to make lifestyle changes

Are you currently receiving care for any urgent or serious medical condition?

No Yes I am unsure

Please do not use this form for urgent medical concerns. If you require urgent medical assistance, contact your GP, NHS 111 or emergency services as appropriate.

I understand that submitting this form does not create a clinician–patient relationship and does not constitute medical advice, diagnosis or treatment. I understand that Beechill Clinic will review the information provided and contact me regarding suitable next steps.

I consent to Beechill Clinic using the information provided to review my enquiry and contact me about appropriate services. I have read the Beechill Clinic Privacy Notice.

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Functional Medicine Application

Contact Info:

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