Ling House Medical Centre Booking Form - Confidential

Prostate Screening Clinic - 20th January 2-4pm

Please check you are eligible for the Prostate Screening Blood Test and read the advantages and disadvantages of this test before signing up : PSA Test

Everyone will need to attend the GP Talk at 2pm prior to the blood test, which will take place in the main waiting room in Ling House Medical Centre.

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* 1. Name

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* 2. Patient Information

Date of Birth - Please note you need to be over the age of 50 to be eligible for this test

Date

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* 3. Are you a Patient at Ling House Medical Centre?

Yes

No - You are not eligible for this test

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* 4. Mobile Phone Number

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* 5. Email Address

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* 6. Do you need any language intepreter support?

Yes

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* 7. Do you consent to your medical records being temporarily shared to WACA Primary Care Network for the purposes of this Prostate Screening Test?

Yes