Request for information

If you are making a request for medical infromation or a letter from your doctor, pleae complete this form.

Please note: when requesting a letter, a print out of medical information may be offered instead.

Your Details

Name *

Date of Birth *

Phone Number *

Email Address *

Your request

Do you require the following: *

Copies of your medical records

Letter of support

Other

What is the information needed for? *

If requesting medical records, please specify date range or exact information required in the box below: *

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Page last reviewed: 16 November 2023
Page created: 25 November 2019

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