Medical Report Form - East Bank Medical Centre

Medical Report/Record Request

If you would like to request a medical report, or want to request copies of your records please use this form.
Please note if you want online access to your records you need to go to our Online Access page.

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Named GP (if known)

Report

What type of medical request would you like to make? *

Occupational Health Advice

HGV Medicals

PIP Summary

Housing support

Travel insurance

Compensation

Personal use full medical record request

Other

Why do you need this report? (please give as much information as possible) *

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. *

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

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Page last reviewed: 19 March 2024
Page created: 16 June 2022

Medical Report/Record Request

Medical Report/Record Request

Further Information