Request For Medical Information

 

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Personal Details
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May be used to identify you
Information Request
Consent

Your request may be subject to a fee, if this is applicable an invoice will be generated and we will contact you to arrange payment. Please note we are unable to release any information prior to payment.

The surgery will contact you when the information is available. The information MUST be collected in person with photo ID. Please state below if you wish to appoint another person to collect your information. 

to collect my information on my behalf and agree that they will bring photo ID to collect the information. I understand that if I choose to share this information with anyone else, this is at my own risk.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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