Medical Evidence Request Form

Medical Evidence Request

First Name *

Last Name *

Date of Birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Email *

GP Name *

Address *

Reason for request, for example, extension to work, reasonable adjustments, sickness absence etc *

Nature of Illness *

Date From *

Please use format day/month/year e.g. 12/05/1979

Date To *

Please use format day/month/year e.g. 12/05/1979

Give a brief description of the impact of this illness on studies, for example on memory or motivation, concentration, anxiety, mobility, daily living etc. *

I give my consent for St Clements Partnership to disclose information from my confidential medical records which is relevant to this request.

Yes

How would you like to receive your report?

I will collect from surgery

Please email it to me (Please note the report will be sent in an unsecured format to the email address you have provided)

Confirm enquiry is not urgent *

I confirm that my enquiry is not urgent, and understand it may take up to 5 working days before I receive a reply.

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Your consent *

I consent to the practice collecting and storing my data from this form.

CAPTCHA

If you are human, leave this field blank.