Medical Report Request Form

PLEASE READ BEFORE COMPLETING REPORT/LETTER REQUEST

Please note there is a minimum fee for this letter of £30, payable at the point of request.

The report can take up to 28 working days to be completed.

If the GP feels that a report is not required or if we are unable to complete the request, we will contact you and refund the money within the 28 days.

If you require a report for university either to explain a medical condition, absence, sickness, additional requirements for exams or extenuating circumstances please discuss this first with the University and the Occupational Health Department. We can supply a summary print out of your medical condition as proof of a medical condition but do not provide reports unless requested specifically by the University. This request needs to be made in writing from the University and there is a charge for the report.

If you require further information, please speak to the Care Co-ordinator Team.

MEDICAL REPORT REQUEST

Please note there is a minimum fee for this letter of £30, payable at the point of request.

The report can take up to 28 working days to be completed.

If the GP feels that a report is not required or if we are unable to complete the request, we will contact you and refund the money within the 28 days.

If you require further information, please speak to the Care Co-ordinator Team.

Your Details

Name *

Date of Birth *

Phone Number *

Email Address *

HOME ADDRESS *

Report

DATE OF REQUEST *

WHOM THE REQUEST IS TO BE MADE TO: *

PLEASE WRITE INFULL DETAILS WHAT THE REQUEST IS FOR AND WHY: *

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: 29 August 2025
Page created: 29 August 2025

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Medical Report Request Form

Medical Report Request Form

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