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How to Prepare for Your Health Screening Medical Thank - The Well

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How to Prepare for Your Health Screening Medical
Thank you again for booking an Executive Medical. Your visit will last about three hours and we would ask that you
please aim to arrive 15 minutes prior to your appointment time to complete your registration.
We have enclosed a questionnaire which you will need to complete and bring with you on the day of your medical. If
you previously visited us for a medical, we would ask that you just include any updated medical details since your
previous visit.
Please also take the time to look through the directions to The Well which we have enclosed. If you have any
problems finding us on the day, please do not hesitate to call us on (01) 294 5444 for further assistance.
In addition please note the following preparation required:
Fasting
You will need to fast for 12-14 hours before your medical. The reason for this is that certain test values may change
after you eat such as blood sugar. It is important to drink water while fasting but no juice, tea or coffee and avoid
smoking, chewing gum or exercising all of which may alter the test results. If you have conditions such as diabetes or
other conditions which may be affected by fasting, please call us on 01-2945444 in advance for further information
Medication
If you are on medication, please continue taking it but be sure to bring the name of it with you as sometimes it can
affect the blood results
FOB Kit (Faecal Occult Blood test)
If you are over 50, an FOB kit will be sent to you in the post prior to your medical. The FOB test is used to check for
blood in the stool which could potentially be a sign of colorectal abnormalities. Detailed instructions will be included as
to how to use. If your booking is confirmed less than 5 days before your medical, we will provide you with am FOB kit
on the day of the medical which will need to be returned at a later date.
Glasses or corrective lenses
If you wear either, please remember to bring glasses or spare contacts as you will be required to take out your contacts
for a specific test.
Body lotion
Please refrain from applying body lotion on the morning of your appointment as it may prevent the ECG pads from
sticking.
Questionnaire
Please complete your medical questionnaire in advance of your medical. It is very important to do this as it will start
preparing you for the medical and it will also ensure that your medical starts on time.
What to wear
Please wear whatever you are comfortable wearing.
If you have any questions about the above, please do not hesitate to contact us on 01-2945444 or by email
info@thewell.ie
Your Day With Us
The day of your appointment
On arrival in �The Well’ at the appointed time, you will be welcomed by our receptionist who will confirm your details
and complete the registration process. You will be then be brought to your room, where you will be based for the
duration of your appointment.
Meeting with the nurse
The medical starts with a meeting with one of our specialist nurses who you will be with for about 75 minutes.
o
o
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o
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The consultation will start with your nurse taking a sample of blood which will be sent to the lab immediately
She will then go through your completed questionnaire and take a full personal and medical history.
The next stage involves the nurse taking your blood pressure, heart rate, weight, height, and body mass index
measurement
You will be asked to provide a urine sample for urinalysis to check liver and kidney function and for infection
A heart assessment (Resting ECG) will then be performed
You will be asked to perform our Spirometry test to check lung function
An eye test is also completed to check visual acuity (Keystone), near and far vision, and a separate test to
screen for glaucoma risks (Tonometry)
Towards the end of the nurses consultation, you will complete a hearing test that will be carried out in our
Audiometry booth
Age based tests:
o
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A DEXA bone scan to screen for Osteoporosis will be performed on women over the age of 40
An FOB test to detect blood in the stools will have been provided for those over the age of 50
Once the consultation with the nurse is completed, you will be provided with a healthy breakfast or a light lunch depending on the time of the day.
Doctor Consultation
The final part of the medical is a meeting with one of our doctors who will be with you for an hour.
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The doctor will complete a head to toe physical examination including a breast or prostate / colorectal
examination as appropriate
He / she will go through and explain the results of all the tests and the assessments carried out including the
blood results.
The doctor will also chat to you about any particular medical concerns that you may have – it is important to
note these concerns on your questionnaire in advance of your medical as you may be too busy to remember
on the day.
Appropriate Diagnostic tests
Based on the results of the medical and following the consultation with your doctor, additional appropriate diagnostic
tests may be completed. Where possible, these will be arranged for the same day or as quickly as possible
afterwards. You should note that all additional tests incur an additional cost so please discuss this with our doctor or
receptionist in advance of completing the test.
The most common additional diagnostic tests are as follows:
Exam / Test
Catalyst
Cost
CT Scan- Angiography
Based on cardiac risk profile
650
Based on clinical examination and / or & risk profile
360
Based on risk profile as determined by sleep questionaire
300
CT Scan of
Brain/Chest/Thorax/Abdomen/Pelvis
(+IV Contrast)
Sleep Apnoea Course
Urine C & S (R)
24 Hour Blood Pressure Monitor
Based on urinalysis containing blood / leucocytes / protein /
glucose
Based on BP x 3 over 140/90. Generally instructed to repeat
with GP beforehand
55
150
Testicular Ultrasound
Based on clinical examination
175
Breast Ultrasound
Based on clinical examination and / or age & risk profile
180
Ultrasound - Thyroid
Based on clinical examination
175
Pelvis/Abdominal Ultrasound
Based on clinical examination
175
Xray (single)
Based on clinical examination
120
Mammogram - Beacon
Based on clinical examination and / or age & risk profile
190
MRI Scan
Based on clinical examination
480
Full STI Screening
Optional Extra
40
�Many of the above tests are not reimbursable by your health insurer at the above locations but you should mention to
The Well Doctor and receptionist what plan you have and they will investigate your options in advance of having the
test performed. You can also visit the following websites to see your entitlements in advance’
www.vhi.ie - www.quinn-healthcare.com - www.aviva.ie/online/health
Med 1 form – Claiming back against personal taxes
If you are paying taxes under the PAYE system, it is possible to claim the cost of certain medical expenses, including
health screening, back against your personal taxes at the end of the year. As from Jan 1st 2009, the relief is granted
at 20% on cumulative medical expenses over €125. Other costs that are covered under this benefit include GP
consultations, prescribed drugs and medications so it is easy enough to reach this threshold of €125.
Follow-up report
A full and detailed report is sent out within 10 days following the medical including a personalised lifestyle plan and
materials to promote a healthy lifestyle. The report is developed by the nurse and doctor and includes a summary of
the results of the tests, recommendations from the doctor and nurse and a detailed and scientifically valid exercise
and nutrition prescription designed with the input from our lifestyle consultants. With the consent of the visitor, a copy
of the report is also sent to their own GP, their primary health care provider to ensure continuity of care.
Female Executive Medical Questionnaire
EXECUTIVE MEDICAL QUESTIONNAIRE
Please complete this confidential questionnaire as fully as possible and bring it with you to
your appointment.
Doctor’s notes
First name:
Surname:
Date of birth:
Home address:
Home telephone no.:
Work telephone no.:
Mobile no.:
Are you:
E-mail:
Single
Married
Divorced
Separated
Widowed
Living with a partner
What is your main reason for attending �The Well’?
Review of Health
Specific Medical Problem
Company related
If company related, what is the name of your company?
If you have any particular health concerns, please note them below:
If you would like your doctor to receive a copy of your report, please give their name,
phone number and address:
Name:
Phone:
Address:
If you have private health insurance, which company are you with?
Vhi
Quinn Healthcare
Hibernian Aviva Health
Other
None
Where did you hear about us?
Would you like to receive a copy of our e newsletter & details of our special offers Yes
No
OCCUPATIONAL HISTORY
Are you currently employed outside of the home?
Yes
Do you work:
Full-time
Part-time
Are you:
Self-employed
Retired
No
If you are not already retired, please complete the following:
What is your current occupation?
Please give details of what your position entails:
Do you currently find your work fulfilling?
Yes
No
1
LIFESTYLE BACKGROUND
SMOKING
Are you:
A current smoker
Do you/did you smoke:
Cigarettes
Ex-smoker
Never Smoked
Doctor’s notes
Cigars
Pipe
Other
If yes, on average how many do/did you smoke daily?
If you have given up smoking, how many years ago did you stop?
years
For how many years have you been a smoker?
years
ALCOHOL
Please give details of your typical weekly alcohol consumption:
(1 standard drink is roughly 1/2 pint of beer, 1 (100ml) glass of wine or 1 (30ml) measure of a spirit)
Beer
Wine
Spirits
None
Total no. of Standard drinks
Are you concerned about the effect of alcohol on your:
Physical health
Yes
No
Psychological health (incl. memory, concentration, moods)
Yes
No
Social well-being
Yes
No
Family life
Yes
No
Work life
Yes
No
How often in a normal week would you drink alcohol?
How many drinks do you have on a typical day when you are drinking?
How often do you have six drinks or more on any one occasion?
DRUGS
Do you take any of the following?
Sleeping tablets
Pain Killers
Cannabis
Cocaine
Other:
EXERCISE AND HOBBIES
Please detail your hobbies, interests and passions:
Please describe your average weekly exercise pattern:
2
FAMILY MEDICAL HISTORY
Are you aware of your family medical history?
If yes, it is very helpful for us to know the following:
Current age
Or age at death
Yes
No
State of health/cause of death
Doctor’s notes
Father
Mother
Partner/Spouse
Brothers
Sisters
Daughters
Sons
Do you have any other particular concerns about your family medical history such as
incidence of bowel, prostate or skin cancer, thyroid disease, mental health or sudden
death under the age of 60?
MEDICAL HISTORY
Please list any history of past significant illnesses or medical conditions (eg. High blood
pressure, raised cholesterol), injuries or accidents - Please list the most recent first:
Please list any hospital admissions and the reason for admission - Please list the most
recent first:
Please detail any investigations/procedures that you may have undergone (endoscopy,
colonoscopy or any other day case procedure):
Please list any medications you are taking and how long you have been taking them:
Please list any allergies (in particular to medications) you may have:
3
WELL-BEING
Would you describe yourself as generally being a happy person?
Yes
No
Persistent worrying
Yes
No
Difficulty in making decisions
Yes
No
Difficulty in relaxing
Yes
No
Difficulty concentrating
Yes
No
Disrupted sleep pattern
Yes
No
Feeling unhappy and depressed
Yes
No
Do you snore loudly?
Yes
No
Do you snore every night?
Yes
No
Have you ever been told that you hold your breath while sleeping?
Yes
No
Have you recently experienced any of the following?
Doctor’s notes
Please give details of any particular concerns you may have:
SLEEP PATTERN
If yes to any of the above, please describe:
Dozing Situation
Chance of Dozing
0= would never doze 1= slight chance of dozing 2= moderate chance of dozing 3= high chance of dozing
Sitting and reading
Watching TV
Sitting inactive in a public place (ie theatre or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic
TOTAL SCORE
DERMATOLOGY
Do you have any previous/present skin problems
such as eczema, psoriasis, acne etc?
Yes
No
Is there any history of melanoma in your family?
Yes
No
Do you have any moles on your skin
that you are concerned about?
Yes
No
Have you ever been severely sunburned?
Yes
No
Do you have any moles that are unusual or changing?
Yes
No
Does anyone in your family have osteoporosis?
Yes
No
Have you had a fracture at low impact?
Yes
No
If yes, please describe:
MUSCULOSKELETAL
4
HEALTH QUESTIONS FOR WOMEN
Are you breast aware - i.e. do you examine your breasts regularly?
Yes
No
Have you ever had a breast problem or needed breast surgery?
Yes
No
Doctor’s notes
If yes, please give details:
Has any member of your family had breast cancer?
Yes
No
Yes
No
If yes, please give details:
Have you ever had a mammogram?
If yes, when and where was it performed and what was the result?
I __________________________________ consent to having the below procedure(s)
performed as discussed by the Doctor:
Pelvic exam
Breast exam
Signed: _____________________________________________
The above is to be signed in the presence of a clinician.
Is there any history of ovarian cancer in your family?
Yes
No
Is your menstrual cycle regular?
Yes
No
Vaginal itching
Yes
No
Bleeding between periods
Yes
No
Discharge
Yes
No
Bleeding after periods
Yes
No
Yes
No
Yes
No
If not, please describe:
Have you recently experienced/noticed any of the following?
If so, please give details:
Have you ever had a cervical smear?
If so, when was your last cervical smear?
Have you ever had an abnormal smear?
If so, please give date and details of any abnormalities:
I __________________________________ consent to having a smear performed as
discussed by the Nurse/Doctor.
Signed: _____________________________________________
The above is to be signed in the presence of a clinician.
Do you have any problems with sexual function?
If so, please specify:
Yes
No
Do you have any concerns regarding Sexually Transmitted Diseases? Yes
No
If so, please specify:
5
CLINICAL FINDINGS – (For office use only)
LIFESTYLE NOTES
Weight:
Height:
Target Weight:
Waist Measure:
Body Fat %:
Target Fat %:
BMI:
Hip Measure:
Ratio:
Water %:
Diet:
Exercise:
Weight Management:
Fitness Score:
Flexibility Score:
Core Stability Score:
BP:
HR:
CLINICAL NOTES
Bloods:
Yes
No
TSH:
Yes
No
Any Additional Tests:
Coronary CT Angio booked:
Yes
No
CT CA booked
Yes
Keystone:
Yes
No
If not why?
Tonometry:
Yes
No
If not why?
Spirometry:
Yes
No
If not why?
Audiometry:
Yes
No
If not why?
Urinalysis:
Yes
No
If not why?
FOB kit given: Yes
No
If not why?
Smear Test taken:
Yes
No
Result:
+:
Findings:
Breast Exam Required:
Yes
No
Chaperone Required:
Yes
No
No
-:
Note:
Last Smear:
Stress Level:
Additional notes:
Any areas of concern:
6
CNS/PNS REVIEW
Headaches/Migraines
Visual disturbance, hearing
RESPIRATORY REVIEW
Shortness of breath
Wheezing
CARDIOVASCULAR REVIEW
Chest pain (symptoms)
Palpitations
GASTROINTESTINAL REVIEW
Acid reflux/Heartburn/indigestion
Altered bowel habit
Blood in the bowel motion
Advised re Screening Colonoscopy
Advised re Diagnostic Colonoscopy
GENITO-URINARY REVIEW
Frequency of urine
Incontinence (stress or urge)
MUSCULOSKELETAL REVIEW
Any Joint problems
SKIN REVIEW
Any skin problems
Moles
PHYSICAL RESULTS
Head and Neck
ENT
Respiratory
Heart
Carotids
Peripheral Pulses
Abdomen
Breast
Genitals
Neurological
Low
Med
High
Yes
No
Yes
CVS Risk
CT Angio
Mole Mapping
Osteoporosis Risk
Dexa
Other Investigations
OSA Risk
Sleep Study
No
7
Notes
8
Beacon Consultants Clinic
Sandyford
Dublin 18
Ireland
Phone: +353 1 294 5444
Fax: +353 1 294 5466
info@thewell.ie
www.thewell.ie
Vhi SwiftCare Clinic
The Plaza, City Gate
Mahon
Cork
Phone: 1800 928820
Fax: +353 21 240 9400
info@thewell.ie
www.thewell.ie
Patient Name:
Date of Birth:
Date of Visit:
The Well Lifestyle Questionnaire
Yes
No
Yes
No
Yes
No
Dietary Habits
Are you currently trying to lose weight?
Are you on a specific diet/weight loss regime?
Give detail of what diets if any you have tried in the past
Are you happy with your weight? If yes, explain
Do have any specific dietary requirements like Coeliac Disease, Diabetes or any food
intolerances?
Have you ever had raised Cholesterol?
If yes are you on medication for same?
Which do you think best describes your current eating pattern?
Tick appropriate
Grazing and nibbling throughout the day
Often skipping meals
Three meals a day
Three meals a days plus snacks
Eating out more than twice a week
Never have breakfast
Food intake breakdown
How many times a week (out of 21 meals) would you eat the following?
Red Meat
Fish
Chicken
Ready Prepared meals
Eating out in Restaurants
Takeaways
Give an example of an average day’s food intake for you
Breakfast
No. of times per week
Lunch
Dinner
Dairy products (ring appropriate full or low fat)
No. of times per week
How many times a week do you consume the following?
Full fat
Low Fat
Milk Full/Low fat
Butter Full/Low fat
Cheese Full/Low fat
Yogurt Full/Low fat
Do you take cream? If yes, how many times a week?
Fruit and Vegetables (portion=1 piece of fruit/1 large serving spoon of Vegetables)
No. per day
How many portions of fruit would you have a day?
How many portions of vegetables would you have a day?
Snacks
No. per day
How often do you snack each day?
Give examples of what you snack on
Junk Food
How often would you eat the following each week?
No. of times per week
Crisps
Chocolate
Chips
Sweets
Liquid intake
How many glasses/cups of the following do you have each day:
No. per day
Water
Juice
Tea
Coffee
Herbal/Fruit Tea
Fizzy drinks
Alcohol
On a weekly basis, how many glasses/pints do you drink each week?
Glasses of wine
Pints of beer
Spirits
No. of glasses/pints per week
Smoking
Have you ever smoked?
Yes
No
Ex
Yes
No
Type
Do you presently smoke? Cigarettes/Cigars
How many do you smoke a day?
Would you like to give up smoking?
Have you ever attempted to give up smoking?
Years
How long have you given up?
What methods have you tried
Exercise. Do you feel you……?
Tick appropriate
Take enough exercise
Need to take more exercise
Do not have time to take exercise
Do not need to exercise
How to Rate Your Activity Level
Tick appropriate
• Very low activity. You spend most of your day sitting. You rarely exercise.
• Low activity. You work in an office, but your day includes some walking, bicycling, or stairclimbing. Or you exercise at least 20 to 45 minutes at least once a week.
• Moderate activity. Your daily routine involves walking or standing most of the day or includes
some brisk or uphill walking or some lifting. Or you exercise at least 20 to 45 minutes about three
times a week.
• Very good level of activity. Your daily routine keeps you moving most of the time or includes
some running, heavy lifting, or swimming. Or you exercise at least 20 to 45 minutes every day.
• Exceptional activity. You're unstoppable. You're training daily for an athletic event, or you're a
professional dancer or athlete with a strenuous schedule.
What would be your regular exercise regime - give details:
Nurse use only:
Weight kg:
Target Weight:
Body Fat%:
Target Fat%:
Water:
Target Water%:
Waist:
Hip:
BP
Pulse
FOB
MSU
Additional Notes:
Height cm:
WH Ratio:
Smear
BMI:
Directions to �The Well’ at the Beacon Consultants Clinic
Directions from the M50
South Bound
•
Take the Sandyford/Dundrum exit from the M50 -
North Bound
• Take the Sandyford exit to the M50
Exit 13
•
Take the third turn off the roundabout towards
• Cross the bridge over the M50
Sandyford
•
Turn left at the next set of traffic lights (at the roundabout) and get into the right hand side lane
•
At the next set of traffic lights turn right, ("Beacon Hotel" on your right).
•
Take the first right on to Blackthorn Road (after about 100metres).
•
About 20m down on the right hand side is an entrance to the underground car park (Beacon
Hotel/Court/Clinic/Hospital car park)
•
You will be directed to the visitors parking area. Take the stairs up to ground level and follow the signs for the
Beacon Clinic, which is in the adjacent building
•
'The Well' is on the ground floor of the Beacon Clinic
Coming from the N11 (Southbound towards Bray – from the City centre)
•
Follow the N11 southbound through Donnybrook and Stillorgan
•
After passing the Stillorgan Park Hotel (on the left) and the Stillorgan village junction, turn right at the next lights (St
John of God hospital on the left hand side) onto Brewery Road
•
At the end of Brewery Road, take the fourth exit off the roundabout, heading into the Sandyford Industrial Estate
•
At the T -junction at the end of this road, (grey Avid building in front of you) turn left onto Blackthorn Road
•
Just before the end of the road on the left hand side is an entrance to an underground car park (Beacon
Hotel/Court/Clinic/Hospital car park). Follow the signs to the Beacon Clinic and �The Well’ is located in the ground
floor
Coming from the N11 (Northbound towards Dublin)
•
Follow the N11 toward Dublin.
•
After passing Foxrock Church (on the right), at the next traffic lights turn left - onto Leopardstown Road
•
At the end of Leopardstown Road (Racecourse on your left) take 3rd exit off the roundabout, heading into the
Sandyford Industrial Estate
•
At the T -junction at the end of this road, (grey Avid building in front of you) turn left onto Blackthorn Road
•
Just before the end of the road on the left hand side is an entrance to an underground car park (Beacon
Hotel/Court/Clinic/Hospital car park)
Coming from Dundrum village via Kilmacud Road Upper
•
At the Dundrum village crossroads, take the Upper Kilmacud Road towards the Sandyford Estate
•
At the fourth set of traffic lights, turn right onto the new road
•
At the next lights (Beacon Hotel across the junction, on your left), turn left
•
Take the next right onto Blackthorn Road (opposite the Alo Kavanagh Mercedes Garage)
•
About 20m down on the right hand side is an entrance to an underground car park (Beacon
Hotel/Court/Clinic/Hospital car park)
By LUAS – on foot only
Going towards Sandyford
Going towards Town
•
Disembark at the "Kilmacud" LUAS stop
•
Walk up the stairs and follow the path to the road
•
Turn left and continue up the road to the 2
traffic lights
• Disembark at the "Kilmacud" LUAS stop
nd
set of
• Walk up the stairs and follow the path to the road
• Turn right and continue up the road to the traffic lights
• Turn left and walk until the next set of traffic lights
•
At the traffic lights, turn left passing the Beacon Hotel on your right and turn right onto Blackthorn road.
•
Take the first turn to the right onto Bracken Road and continue up the road for about 300m
•
There is an entrance to Beacon Court on the right hand side (sand coloured walls with water coming down the walls
and flags at the entrance)
•
Go through the security barrier and continue down the avenue
•
The Beacon Clinic is the last building on your left hand side
•
'The Well' is located on the ground floor of the Beacon Clinic
If you have any problems finding us, please call us on 01-2945444 and we will direct you further
Mount Anville Rd
Taney Rd
Dundrum
Town
Centre
GOAT PUB
Lower Kilmacud Rd
Balally S.C
BEACON
HOTEL
KILMACUD
LUAS STOP
MERCEDES BENZ
B L AC K T
The Well
BEACON
CLINIC
HORN D
LONDIS
RIVE
LUAS PARKING
ENTRANCE
TO CAR PARK
Bracken Rd
MICROSOFT
STILLORGAN
LUAS STOP
LUAS PARKING
AVID
BLACKTHORN AVENUE
Heather Rd
BLACKTHORN ROAD
Furze Rd
Kilmacud Rd
LUAS line
BLACKTHORN ROAD
AIB
SANDYFORD
LUAS STOP
Arena Rd
and
y fo
rd
WOODIES DIY
EXIT 13
M50
BURTON HALL ROAD
to S
AD
Y RO
WER
BRE
Central Park
Bewleys
Hotel
RACECOURSE
Business Park
The Well, Beacon Clinic, Sandyford Industrial Estate, Dublin 18
Ph: 01-2945444 Fax: 01-2945466 Email: info@thewell.ie www.thewell.ie
N11
M50
DRUMMARTIN LINK ROAD
VHI SWIFTCARE
BALALLY
LUAS STOP
Kilmacud Rd Upper
BEACON HOSPITAL AND CLINICS
VISITOR MAP
Beacon
Consultants Clinic
Suites 1-32
The Avenue
- Advanced Radiology
- Beacon Dental Clinic
- Beacon Eye Clinic
- Cancer Support Centre
- The Well
Beacon
Consultants Concourse
Suites 1-12
Second Floor
The Concourse Building
Beacon Hall
Suite 36
- Beacon Dermatology
- Beacon Medical Group
- Motivation Weight Management Clinic
- Sandra Cummings (Audiologist)
- Wellington Eye Clinic
THE AVENUE
Advanced Radiology
Reception
Suite 8
SOUTH MALL
Pharmacy
Monday - Friday
8.30am to 6pm
NORTH MALL
THE CONCOURSE
Beacon
Hotel
Beacon
Renal
Suite 35
Lift
Pharmacy
Beacon
Hospital
First Floor
Revolving Door
Information Desk
Hospital Entrance
Beacon Hospital
Reception Lobby
Information Graphic by LoinesFurnival В© 2007 www.l-f.co.uk
Main Entrance
Photo Guided Tour
Photo Walk Through
Directions from the Lift
From Blackthorn Road, turn into the Beacon car park.
Turn right and go through the barrier.
Keep the security room on your left hand side
Park and walk to the “Beacon Court Entrance”
Take the lift to the Concourse Level by Pressing “0”
On exiting the lift, turn left into the Concourse (common seating area)
Walk to the far right hand side of the open area to the revolving door.
Walk through the revolving door
Walk until you get to the miniature model of the Beacon Complex
Turn right at the model and go through the door
The Beacon Consultant Clinic is straight ahead. The Well is located on the ground floor
of the Clinic
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