Medical Report Form - Woodlands & Clerklands Partnership

Request a private letter

If you would like to request a private letter, please use this form.

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Report

Who should the letter be addressed to? *

Why do you need this letter? *

Are there any specific details which need to be included in the letter? *

By completing this form, you acknowledge that there is a charge payable for this letter. Until you have paid the charge, the doctor will not prepare your letter. *

I understand and agree.

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. The information on this form will be stored in our website provided by My Surgery Website for up to one month before being deleted. 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: 11 May 2023
Page created: 30 May 2023

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Request a private letter

Request a private letter

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