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Request for the Completion of a Form, Letter or copy of Medical Record

Forms and Letters

Please complete the information on the reverse of this form if you are requesting a form to be completed or a letter provided by a clinician.  Please also submit with this document the form you require completing or your written request for a letter. These are usually completed within 28 working days, however, if there is a particular clinician that needs to complete the form the timescale may be extended.

There may be a charge for completing your letter or form. We will contact you once we have reviewed your request and inform you of the fee for your agreement prior to starting the work. 

Payment will need to be paid in advance at reception prior to work being started.   

Subject Access requests

If you are requesting information under the General Data Protection Regulations 2018.  Access to your Medical Records (for example medical records, results  and vaccination information), you will need to complete the reverse form and also attach your request for information.  There will be no charge for this information and it will be ready to collect within 1 month from the request date.   There will be a charge for any subsequent copies of the same information.


A member of the team will inform you when this is ready to collect, if you have not heard anything after 20 working days please call 0116 2151105.

The information will only be released to the patient or their nominated party. Please note we will not, under any circumstances release this information without the proper and correct Identification. If we are suspicious of anyone collecting information on behalf of another person we will withhold the information until the data subject has been contacted.

If you wish for some else to collect your information please fill in the form below and ensure that person brings in photographic identification (passport, driving licence, national ID card).

Request for the completion of a Medical Form, Letter or copy Medical Record

Patient’s Details

Include Flat, Room, Block Number and House Name
Enter Email
Confirm Email

Details of the Person who requesting IF DIFFERENT FROM ABOVE

Include Flat, Room, Block Number and House Name

Privacy Policy

Please tick the relevant statements *
What part of your Medical record would you like? *
If you have the form in digital format please upload it

Maximum file size: 10MB

If you DO NOT have the form digitally please hand to Reception as soon as possible. We accept pdf files only, up to a total upload size of 5MB. If completing this form using a smartphone or tablet download a ‘PDF Scanner’ app to take pictures.
Upon the completion of request how would you like to recieve the documentation