AMC Other referrals - Abington Medical Centre

AMC Other Private Services Request

You will be contacted once your request has been actioned. This may take up to 10 working days

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Private Services Request

What type of Private Service Do you Require? *

Private Sick Note

Fitness to Travel/Participate

Passport/Driving License Signature

Copy of Full Medical Records

Copy of Small Medical Records

Copy of Test Results

Holiday Cancellation Form

Details of Request *

I ACKNOWLEDGE THIS PROCESS CAN TAKE UP TO 28 DAYS AND I WILL AWAIT CONTACT FROM THE SURGERY FOR ANY FURTHER UPDATES *

I acknowledge the above statement.

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: 22 October 2020
Page created: 01 October 2020

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AMC Other Private Services Request

AMC Other Private Services Request

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